Long-term effects on function,health-related quality of life and work ability after structured physiotherapy including a workplace intervention. A secondary analysis of a randomised controlled trial (WorkUp) in primary care for patients with neck and/or back pain

Abstract

Objective: To study the long-term effects of a workplace intervention in addition to structured physiotherapy regarding self-reported measures in patients with acute/subacute neck and/or back pain.

Design: WorkUp – a cluster-randomised controlled trial in 32 primary care centers in Sweden, from January 2013 through December 2014 (ClinicalTrials.gov ID: NCT02609750).

Intervention: Structured physiotherapy with the workplace dialogue ‘Convergence Dialogue Meeting’ (CDM), conducted by the treating physiotherapist as an add-on. Reference group received structured physiotherapy.

Subjects: Adults, 18–67?years (mean 43.7, standard deviation (SD) 12.2), 65.3% women with acute/subacute neck and/or back pain who had worked ≥4?weeks past year, considered at risk of sick leave or were on short-term sick leave (≤60?days) were included (n?=?352).

Outcome measures: Self-reported function, functional rating index (FRI), health-related quality of life (EQ-5D-3L) and work ability (Work Ability Score, WAS) at 12 months follow-up.

Results: The mean differences in outcomes between intervention and reference group were; ?0.76 (95% confidence interval (CI): ?2.39, 0.88; FRI), 0.02 (95% CI: ?0.04, 0.08; EQ-5D-3L) and ?0.05 (95% CI: ?0.63, 0.53; WAS). From baseline to 12?months, the intervention group improved function from 46.5 (SD 19.7) to 10.5 (SD 7.3) on FRI; health-related quality of life from 0.53 (SD 0.29) to 0.74 (SD 0.20) on EQ-5D and work ability from 5.7 (SD 2.6) to 7.6 (SD 2.1) on WAS.

Conclusion: Despite a clinically relevant improvement over time, there were no significant differences in improvement between groups, thus we conclude that CDM had no effect on self-reported measures in this study.

• Key points

• In earlier analysis of the primary outcome (work ability measured by absenteeism) in this trial, a positive effect was found when the workplace intervention ‘Convergence Dialogue Meeting’ (CDM) was added to structured physiotherapy for patients with neck or back pain.

• By contrast, in this new analysis of secondary outcomes (self-reported function, health and perceived work ability), there was no added effect of CDM above structured physiotherapy alone, although patients in both the intervention and reference group improved over time.

• The addition of CDM to physiotherapy is therefore justified by its specific effect on behavior (work absence) rather than any effect on clinical outcomes.

     

Cognitive function and health-related quality of life four years after cardiac arrest

AimNeuropsychological testing has uncovered cognitive impairment in cardiac arrest survivors with good neurologic outcome according to the cerebral performance categories. We investigated cognitive function and health-related quality of life four years after cardiac arrest.MethodsThirty cardiac arrest survivors over the age of 18 in cerebral performance category 1 or 2 on hospital discharge completed the EQ-5D-5L and HADS questionnaires prior to cognitive testing using the Cambridge Neuropsychological Test Automated Battery. The results were compared with population norms.ResultsTwenty-nine per cent of patients were cognitively impaired. The pattern of cognitive impairment reflects dysfunction in the medial temporal lobe, with impaired short-time memory and executive function slightly but distinctly affected. There was a significant reduction in quality of life on the EQ-VAS, but not on the EQ index.ConclusionCognitive impairment four years after cardiac arrest affected more than one quarter of the patients. Short-term memory was predominantly affected.     

Ambulatory activity in stroke survivors associated with functional outcome and quality of life: An observational cohort study

BackgroundPhysical activity is beneficial in stroke prevention and recovery. Understanding activity dynamics and its effect on outcome after stroke is important to improve recommendations and develop interventions.ObjectivesWe examined serial changes in daily ambulatory activity (AA) averaged over 1 week in people with subacute to chronic stroke and its association with functional outcome (modified Rankin scale [mRS]) and quality of life (EQ-5D-3L).MethodsThis observational study examined AA in stroke survivors with no to moderate disability (US National Institute of Stroke Scale [NIHSS] score) who were mostly community dwelling and had cryptogenic stroke based on data from the Continuous Cardiac Monitoring to Assess Atrial Fibrillation After Cryptogenic Stroke study. The participants underwent long-term AA monitoring by accelerometric activity data obtained from an insertable cardiac monitor without receiving any specific encouragement regarding physical activity. We analysed AA changes and assessed the association between baseline AA and mRS/EQ-5D-3L scores. A small group of participants had follow-up data for 2 years, which allowed for analysing long-term serial changes.ResultsWe included 186 participants (mean [SD] age 61.3 [11.2] years, 67% male, mean 39 [28] days after stroke). AA increased during the subacute phase in individuals with mild (NIHSS score 1–4, P < 0.001) and moderate (NIHSS score 5–10, P = 0.013) disability but not in the non-impaired group. Baseline AA was inversely associated with NIHSS score (P < 0.001) and was associated with mRS score (P = 0.001) and weakly correlated with EQ-5D-3L score at 6 months (P = 0.032, r = 0.22). For the 45 participants with follow-up data (mean age 64.5 [9.7] years, 80% male, mean 34 [21] days after stroke), AA remained stable.ConclusionAA increased in stroke survivors with impairments but remained stable in those whose symptoms had resolved. AA during the early subacute period was associated with mRS and EQ-5D-3L scores at 6 months. Insertable cardiac monitoring offers a feasible method for monitoring activity over prolonged periods in people after stroke. Its increased use may offer an opportunity to overcome the limited reliability and validity of many existing measures.Trial registrationClinicalTrials.gov (NCT00924638).     

Career readiness,developmental work personality and age of onset in young adult central nervous system survivors

Purpose: The primary purpose of this paper is to undertake foundational research in the area of career readiness, work personality and age of onset with young adult central nervous system (CNS) survivors. Method: Participants for this study consisted of 43 individuals whose age range from 18 to 30 (M = 21.64, SD = 3.46), an average age of brain tumor onset of 9.50 years (SD = 4.73) and average years off of treatment of 7.25 years (SD = 5.80). Packets were distributed to survivors who were participating in a psychosocial cancer treatment program. Participants completed multiple career instruments and a demographic form. Differences between groups and among the variables were examined and size effect sizes were analyzed. Results: Young adult CNS survivors had significantly lower levels of work personality and career readiness when compared to young adult non-cancer survivors with CNS cancer with those between the ages of 6 and 12 reported significantly lower levels when compared to individuals diagnosed before age 6 and after the age of 13. Conclusions: Young adult CNS survivors at an increased risk for having lower levels of work personality and career readiness then a norm group comparison. Age of onset (between 6 and 12) may be at significant risk factor for developing poor or dysfunctional work and career behaviors.

Implications for Rehabilitation

• Young adults with central nervous system (CNS) cancer are at particular risk for experiencing difficulties related to career and employment.

• Work personality and career readiness are two constructs that have been found to be related to one’s ability to meet the demands of work.

• Young adult CNS cancer survivors have lower levels of work personality and career readiness.

• Individuals diagnosed between the ages of 6 and 12 may be at particular risk and may need specific vocational rehabilitation interventions.

• The results of this study point to the need for comprehensive career and vocational services for young adult CNS cancer survivors.

     

Associations between functional capacity,isokinetic leg strength,sleep quality and cognitive function in multiple sclerosis patients: a cross-sectional study

ABSTRACT

Objectives: Recent evidence suggests an association between functional capacity and cognitive function, at least in older adults. The aim of this cross-sectional study was to examine the association between cognitive function, functional capacity, isokinetic leg strength, health-related quality of life (HRQOL), sleep quality, body fat, handgrip strength, and fatigue among a sample of MS patients.

Methods: Fifty-one relapsing-remitting MS patients (age: 38.4 ± 7.1 yrs; 30 females) were recruited and agreed to participate in this study. Cognitive function was assessed by the Paced Auditory Serial Addition Test (PASAT). Functional capacity was examined using various functional tests commonly used in MS patients. Maximal voluntary unilateral leg strength was assessed using isokinetic dynamometer. Isometric handgrip strength was assessed by a dynamometer. Total body and visceral fat levels were assessed via bioelectrical impedance analyzers. Finally, the patients’ HRQOL, sleep quality, and fatigue levels were evaluated using specific questionnaires.

Results: A significant association was found between the PASAT score and the performance score in various functional capacity tests (p < 0.050). On the other hand, a weak but statistically significant association was found between the PASAT score and isokinetic strength of knee extensors (r = 0.319, p = 0.022) and knee flexors (r = 0.354 p = 0.011). Poor sleep quality was associated with lower performance in all the functional capacity tests examined (p < 0.05) whilst was negatively associated with the PASAT score (r = ?0.334, p = 0.017). The multivariate regression analysis revealed that the performance on the TUG test was a significant predictor of cognitive function.

Conclusion: Based on the results of this study, functional capacity was found to be associated with both impaired cognitive performance and low HRQOL in MS patients. In addition, an association between sleep quality and cognitive performance was revealed, confirming existing literature. Functional capacity as assessed by the TUG test emerged as the best predictor of cognitive function.     

Correlation of patient-reported outcome measures to performance-based function in critical care survivors: PREDICTABLE

BackgroundEstablishing sequela following critical illness is a public health priority; however, recruitment and retention of this cohort make assessing functional outcomes difficult. Completing patient-reported outcome measures (PROMs) via telephone may improve participant and researcher involvement; however, there is little evidence regarding the correlation of PROMs to performance-based outcome measures in critical care survivors.ObjectivesThe objective of this study was to assess the relationship between self-reported and performance-based measures of function in survivors of critical illness.MethodsThis was a nested cohort study of patients enrolled within a previously published study determining predictors of disability-free survival. Spearman's correlation (r_s) was calculated between four performance-based outcomes (the Functional Independence Measure [FIM], 6-min walk distance [6MWD], Functional Reach Test [FRT], and grip strength) that were collected during a home visit 6 months following their intensive care unit admission, with two commonly used PROMs (World Health Organization Disability Assessment Scale 2.0 12 Level [WHODAS 2.0] and EuroQol-5 Dimension-5 Level [EQ-5D-5L]) obtained via phone interview (via the PREDICT study) at the same time point.ResultsThere were 38 PROMs obtained from 40 recruited patients (mean age = 59.8 ± 16 yrs, M:F = 24:16). All 40 completed the FIM and grip strength, 37 the 6MWD, and 39 the FRT. A strong correlation was found between the primary outcome of the WHODAS 2.0 with all performance-based outcomes apart from grip strength where a moderate correlation was identified. Although strong correlations were also established between the EQ-5D-5L utility score and the FIM, 6MWD, and FRT, it only correlated weakly with grip strength. The EQ-5D overall global health rating only had very weak to moderate correlations with the performance-based outcomes.ConclusionThe WHODAS 2.0 correlated stronger across multiple performance-based outcome measures of functional recovery and is recommended for use in survivors of critical illness.     

Long-term fatigue after perimesencephalic subarachnoid haemorrhage in relation to cognitive functioning,mood and comorbidity

Purpose: To study relationships between fatigue and objective and subjective cognitive functioning, mood and comorbidity in the long term after perimesencephalic subarachnoid haemorrhage (PM-SAH).

Methods: Cross-sectional study. Objective cognitive functioning was measured with: Trail Making Test; Symbol Substitution; D2; Verbal and Semantic Fluency; Tower Test; Digit Span; 15-Words Test; Rey Complex Figure. Subjective cognitive functioning: Cognitive Failure Questionnaire. Fatigue: Fatigue Severity Scale. Mood: Hospital Anxiety and Depression Scale.

Results: Forty-six patients, mean age 50.4 (SD?=?9.4), mean time after PM-SAH 4.7 (SD?=?1.6) years participated. Patients with fatigue (33%) had significantly lower scores than patients without fatigue on most objective cognitive functioning tests (p?Conclusions: This study supports our previous findings that a third of patients with PM-SAH experience fatigue and problems of cognitive functioning, also in the long term. Future research should investigate whether these patients would benefit from long-term follow-up and/or cognitive rehabilitation programmes.

• Implications for Rehabilitation

• Consequences for patients with PM-SAH are underestimated.

• One in every three patients suffered from fatigue in the long term after onset of PM-SAH.

• Patients with PM-SAH should be screened for problems of cognitive functioning, fatigue and mood in outpatient clinic just as patients with aneurysmal SAH.

     

The effect of prehabilitation on the range of motion and functional outcomes in patients following the total knee or hip arthroplasty: A pilot randomized trial

Objective: The study investigated the effect of prehabilitation on the quality of life and function in patients having total knee replacement (TKR)/total hip replacement (THR). Methods: A pilot randomized controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis was conducted. Sixty-four people undergoing elective lower-limb arthroplasty were included. Prehabilitation included one-hour twice-weekly sessions for at least three and a maximum of four weeks prior to surgery. Control participants did not complete any pre-surgical programs. Health utility and quality of life as measured by the EQ-5D-3L and the patient-specific functional scale were the primary outcomes measured before allocation and eight weeks post-operatively. Results: No between-group differences were evident in health utility (main effect of the group ?0.04 (95% Confidence Interval [CI] ?0.16 to 0.08, p = 0.50) or patient-specific functional scale (main effect of the group ?0.59 (95% CI ?1.8 to 0.6, p = 0.73), but the group-by-joint interaction effects for the timed up and go (TUG) (7.6 (95% CI ?0.9 to 16.1, p = 0.08)) and the EQ-5D VAS (?18.3 (95% CI ?41.1 to 4.5), p = 0.11) were larger. Prehabilitation participants’ knee flexion improved by 12.6 degrees (95% CI 5.2–20, p = 0.001). Conclusions: Prehabilitation improved knee flexion, but this did not translate into improved functional mobility or quality of life.     

Predicting length of stay in patients admitted to stroke rehabilitation with high levels of functional independence

Purpose.?In Ontario, stroke patients with relatively mild functional deficits are admitted to inpatient rehabilitation programmes. Despite apparently minor impairments, many of these patients remain in rehabilitation for prolonged periods of time. The objective of the present study is to identify variables that predict length of stay (LOS) within this population of high functioning stroke patients.

Methods.?Stroke patients with Functional Independence Measure (FIM?) scores?≥100 admitted to a specialised inpatient rehabilitation programme in Ontario, Canada, from April 2005 to March 2008 were included in this study. Data from the National Rehabilitation Reporting System and chart review were used. Associations with LOS were examined among 25 potential predictor variables using bivariate correlations. Significantly correlated (p <0.002) variables were entered into a multiple linear regression.

Results.?Twenty-four percent (n == 134) of patients admitted during the study period were identified as presenting with mild functional deficits. These patients had a mean admission age of 63.5 (SD 14.6) years, a mean admission FIM score of 109.9 (SD 6.6) and a mean LOS of 22.3 (SD 10.5) days. FIM motor and cognitive subscale scores, Mini Mental State Exam scores and five single items assessing orientation, financial independence, and verbal, written and auditory communication ability were significantly correlated with LOS. The regression model, which included all eight variables, explained 60%% of the variance associated with LOS (r == 0.80).

Conclusions.?For patients admitted to stroke rehabilitation programmes with mild functional impairment, 60%% of the variance in LOS can be explained by a small number of variables indicative of deficits in the areas of motor function, cognition and communication.     

Does treadmill training with Hybrid Assistive Limb (HAL) impact the quality of life? A first case series in the United States

Abstract

Introduction: Recently published studies show remarkable improvements in functional mobility after treadmill training with HAL^® in patients with spinal cord injuries. The aim of this study was to evaluate the impact of HAL^®-assisted treadmill training on quality of life.

Patient/Method: A case series of six patients participating in a single-centre prospective, interventional pilot study, who were suffering neurologic motor deficits. The quality of life was assessed using the EQ-5D questionnaire and mobility was assessed using the PROMIS v1.2 Physical Function – Mobility Score before treadmill training, at 12-weeks, and at 6-months.

Results: Five out of six patients showed improvement in the PROMIS v1.2 Physical Function – Mobility score. Four patients did not show changes in the EQ-5D at 6 months follow-up, relative to baseline. The EQ-5D score of one patient worsened while improved in another patient at 6 months follow-up compared to the baseline.

Conclusion: Our study details the first experience in a larger series regarding the effects of HAL^®-assisted treadmill training on quality of life. Whereas five out of six patients showed improvements in mobility scores, only one patient showed improvement of life quality at 6 months follow-up. Life quality is influenced by a multitude of factors and lager randomized trials are needed to assess the effect of HAL^®-assisted training on quality of life.

• Implications for Rehabilitation

• Treadmill training with HAL is safe and feasible for patients with neurologic disorders

• Treadmill training with HAL improved the functional mobility

• Improvements in the quality of life were unverifiable

     

Recent Advances in Monoclonal Antibody Therapies for Multiple Sclerosis

ABSTRACT

Introduction: Multiple sclerosis (MS) is the most common chronic inflammatory, demyelinating disease of the CNS and results in neurological disability. Existing immunomodulatory and immunosuppressive approaches lower the number of relapses but do not cure or reverse existing deficits nor improve long-term disability in MS patients.

Areas Covered: Monogenic antibodies were described as treatment options for MS, however the immunogenicity of mouse antibodies hampered the efficacy of potential therapeutics in humans. Availability of improved antibody production technologies resulted in a paradigm shift in MS treatment strategies. In this review, an overview of immunotherapies for MS that use conventional monoclonal antibodies reactive to immune system and their properties and mechanisms of action will be discussed, including recent advances in MS therapeutics and highlight natural autoantibodies (NAbs) that directly target CNS cells.

Expert Opinion: Recent challenges for MS therapy are the identification of relevant molecular and cellular targets, time frame of treatment, and antibody toxicity profiles to identify safe treatment options for MS patients. The application of monoclonal antibody therapies with better biological efficacy associated with minimum side effects possesses huge clinical potential. Advances in monoclonal antibody technologies that directly target cells of nervous system may promote the CNS regeneration field from bench to bedside.     

Anti-endothelial cell antibodies (AECA) in patients with systemic vasculitis: our research using proteomics

Importance of the field: Anti-endothelial cell antibodies (AECA) may cause damage to endothelial cell (EC) functions and therefore may be of a pathophysiological role in systemic vasculitis. The pathophysiological role of AECA, however, is still uncertain.

Areas covered in this review: To clarify the detailed roles of AECA, various methods for identification of target proteins of AECA have been developed, such as expression libraries and proteomic approaches combining two-dimensional electrophoresis and immunoblotting.

What the reader will gain: Advances, including our research, have been made in defining the target antigens of AECA, which we summarize in this review. Furthermore, we discuss the possible significance of AECA in the pathophysiology of vascular damage and the value of AECA in systemic vasculitis.

Take home message: To identify target antigens of AECA and to establish a standardized method for measuring AECA would be helpful in the search for a possible pathophysiological role of AECA in systemic vasculitis.     

Endocarditis-associated rapidly progressive glomerulonephritis mimicking vasculitis: a diagnostic and treatment challenge

BackgroundInfective endocarditis (IE)-associated rapidly progressive glomerulonephritis (RPGN) is rarely reported. Sporadic case reports have noted the diagnostic and therapeutic challenge in IE-associated glomerulonephritis because it may masquerade as idiopathic vasculitis.MethodsPatients with clinical diagnosis of IE-related RPGN in a tertiary hospital in China between January 2004 and May 2021 were identified and retrospectively reviewed.ResultsTwenty-four patients with IE-associated RPGN were identified. All patients presented with fever and multiorgan system involvement on top of heart and kidneys, spleen (79%, 19/24), skin (63%, 15/24), lung (33%, 8/24) and nervous system (17%, 4/24). Six of the 24 patients (25%) were initially suspected to have ANCA-associated or IgA vasculitis. Forty-five percent of patients are seropositive for ANCA. Renal histology showed mesangial and/or endocapillary hypercellularity with extensive crescents in most patients. C3-dominant deposition was the predominant pattern on immunofluorescence and pauci-immune necrotising crescentic glomerulonephritis was observed in one case. All patients received antibiotics with or without surgery. Six patients received immunosuppressive therapy before antibiotics due to misdiagnosis and seven patients received immunosuppressive therapy after antibiotics due to persistence of renal failure. Three of the 24 patients died due to severe infection. All the surviving patients had partial or complete recovery of renal function.ConclusionIE-associated RPGN is rare and the differential diagnosis from idiopathic vasculitis can be challenging due to overlaps in clinical manifestations, ANCA positivity and absence of typical presentations of IE. The prognosis is generally good if antibiotics and surgery are not delayed. The decision on introducing immunoruppressive treatment should be made carefully on a case by case basis when kidney function does not improve appropriately after proper anti-infective therapy.

Key messages

• Infective endocarditis associated RPGN is rare and differentiating it from idiopathic vasculitis can be challenging due to overlap in clinical manifestations, ANCA positivity and occasional absence of typical manifestations of infective endocarditis.
• Kidney function usually responds to antibiotic therapy alone.
• Immunosuppressive therapy may be beneficial in carefully selected patients whose kidney function does not improve with antibiotics alone.

     

Vasculitides and glomerulonephritis associated with Staphylocococcus aureus infective endocarditis: cases reports and mini-review of the literature

Abstract

We reported two cases of Staphylococcus aureus Infective Endocarditis associated with vasculitides and glomerulonephritis respectively, before conducting an online search of previously published similar cases reports. Twenty five references were selected: 15 cases of glomerulonephritis; 2 cases of vasculitis and 8 cases involving both glomerulonephritis and vasculitis. Vasculitides and glomerulonephritis associated with Staphylococcus aureus definite Infective Endocarditis have been reported since 1976. All cases except one described clinical symptoms occurring before or during initial antibiotics treatment. Except kidney, organs that were more frequently affected by vasculitis process were skin, gastrointestinal tract and peripheral nerve and the vessels involved were small to medium size vessels. When antineutrophil cytoplasmic antibodies were evidenced (6 out of the 25 cases (24%)), kidney was the most frequently affected organ. The most commonly observed pattern in Kidney biopsy was membranoproliferative glomerulonephritis with endocapillary proliferation sometimes associated with extra capillary crescents, whether or not antineutrophil cytoplasmic antibodies were evidenced. Right-sided Infective Endocarditis (especially in intravenous drug users) were overrepresented (14 of the 25 cases (56.0%)) in this review. Besides antibiotics, corticosteroids were the most frequently prescribed immunosuppressive treatment both for vasculitides or glomerulonephritis.

• KEY MESSAGES

• Vasculitides and glomerulonephritis associated with Staphylococcus aureus definite Infective Endocarditis have been reported since 1976.

• Except kidney, organs that were more frequently affected (by small to medium size vessel vasculitis) were skin, gastrointestinal tract and peripheral nerve.

• The most commonly observed pattern in Kidney biopsy was membranoproliferative glomerulonephritis with endocapillary proliferation and right-sided Infective Endocarditis (especially in intravenous drug users) were overrepresented in this review.

     

Critically ill patients with severe immune checkpoint inhibitor related neurotoxicity: A multi-center case series

PurposeSerious immune checkpoint inhibitor (ICI)-related neurotoxicity is rare. There is limited data on the specifics of care and outcomes of patients with severe neurological immune related adverse events (NirAEs) admitted to the Intensive Care Unit (ICU).Materials and methodsRetrospective study of patients with severe NirAEs admitted to the ICU at 3 academic centers between January 2016 and December 2018. Clinical data collected included ICI exposure, type of NirAE (central [CNS] or peripheral nervous system [PNS) disorders), and patient outcomes including neurological recovery and mortality.ResultsSeventeen patients developed severe NirAEs. Eight patients presented with PNS disorders; 6 with myasthenia gravis (MG), 1 had a combination of MG and polyneuropathy and 1 had Guillain-Barre syndrome. Nine patients had CNS disorders (6 seizures and 5 had concomitant encephalopathy. During ICU admission, 65% of patients required mechanical ventilation, 35% vasopressors, and 18% renal replacement therapy. The median ICU and hospital length of stay were 7 (2–36) and 18 (4–80) days, respectively. Hospital mortality was 29%. At hospital discharge, 18% of patients made a full neurologic recovery, 41% partial recovery, and 12% did not recover.ConclusionSevere NirAEs while uncommon, can be serious or even life-threatening if not diagnosed and treated early.     

Multiple brain networks support processing speed abilities of patients with multiple sclerosis

Objectives: Many people affected by multiple sclerosis (MS) experience cognitive impairment, especially decreases in information processing speed (PS). Neural disconnection is thought to represent the neural marker of this symptom, although the role played by alterations of specific functional brain networks still remains unclear. The aim is to investigate and compare patterns of association between PS-demanding cognitive performance and functional connectivity across two MS phenotypes.

Methods: Forty patients with relapsing-remitting MS (RRMS) and 25 with secondary progressive MS (SPMS) had neuropsychological and MRI assessments. Multiple regression models were used to investigate the relationship between performance on tests of visuomotor and verbal PS, and on the verbal fluency tests, and functional connectivity of four cognitive networks, i.e. left and right frontoparietal, salience and default-mode, and two control networks, i.e. visual and sensorimotor.

Results: Patients with SPMS were older and had longer disease history than patients with RRMS and presented with worse overall clinical conditions: higher disease severity, total lesion volume, and cognitive impairment rates. However, in both patient samples, cognitive performance across tests was negatively correlated with functional connectivity of the salience and default-mode networks, and positively with connectivity of the left frontoparietal network. Only the visuomotor PS scores of the RRMS group were also associated with connectivity of the sensorimotor network.

Conclusions: PS-demanding cognitive performance in patients with MS appears mainly associated with strength of functional connectivity of frontal networks involved in the evaluation and manipulation of information, as well as the default mode network. These results are in line with the hypothesis that multiple neural networks are needed to support normal cognitive performance across MS phenotypes. However, different PS measures showed partially different patterns of association with functional connectivity. Therefore, further investigations are needed to clarify the contribution of inter-network communication to specific cognitive deficits due to MS.     

Correlates of depressive symptoms in individuals attending outpatient stroke clinics

Background and purpose Depressive symptoms are common post-stroke. We examined stroke deficits and lifestyle factors that are independent predictors for depressive symptomology. Methods A retrospective chart review was performed for patients’ post-stroke who attended outpatient clinics at a hospital in Southwestern Ontario between 1 January 2014 and 30 September 2014. Demographic variables, stroke deficits, secondary stroke risk factors and disability study measures [Patient Health Questionnaire-9 (PHQ-9) and Montreal Cognitive Assessment (MoCA)] were analyzed. Results Of the 221 outpatients who attended the stroke clinics (53% male; mean age?=?65.2?±?14.9 years; mean time post-stroke 14.6?±?20.1 months), 202 patients were used in the final analysis. About 36% of patients (mean?=?5.17?±?5.96) reported mild to severe depressive symptoms (PHQ-9?≥?5). Cognitive impairment (CI), smoking, pain and therapy enrollment (p?r=??0.39, p?Conclusions High levels of depressive symptoms are common in the chronic phase post-stroke and were partially related to cognition, pain, therapy enrollment and lifestyle factors.

• Implications for Rehabilitation

• Stroke patients who report cognitive deficits, pain, tobacco use or being enrolled in therapy may experience increased depressive symptoms.

• A holistic perspective of disease and lifestyle factors should be considered while assessing risk of depressive symptoms in stroke patients.

• Patients at risk for depressive symptoms should be monitored at subsequent outpatient visits.

     

Traditional Chinese medicine for gait disturbance in adrenoleukodystrophy: A case report and review of literature

BACKGROUNDAdrenoleukodystrophy (ALD) is caused by a deficit in the ABCD1 gene, which leads to demyelination of neurons and dysfunction of the adrenal cortices and testicles. Of the three known phenotypes, 30%-50% of male ALD patients present with the adrenomyeloneuropathy phenotype, characterized by gait disturbance as the initial symptom.CASE SUMMARYA 46-year-old man with a prior diagnosis of ALD was admitted to a Korean medicine hospital for the treatment of gait disturbance. His ability to walk was severely impaired at admission, significantly affecting the patient’s quality of life. He was treated with acupuncture, pharmacopuncture, electroacupuncture, and herbal medicine for 23 d. The 25-Foot Walk test (25FW), timed up and go (TUG), comfortable gait speed (CGS), numeric rating scale (NRS), Berg Balance Scale (BBS), Tinetti test, manual muscle test (MMT), and 3-level version of EuroQol-5 dimension (EQ-5D-3L) were used to evaluate the patient. The outcomes of the 25FW, TUG, and CGS improved during hospitalization. From the time of admission to discharge we observed: A decrease in NRS scores in the lower extremities and the lower back; an increase of 3 points in the BBS; a 1-point increase in the balancing part of the Tinetti Test; MMT and EQ-5D-3L performances remained unchanged.CONCLUSIONTraditional Chinese medicine treatments could be a therapeutic option to alleviate issues related to gait disturbance in ALD.