Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: A randomised controlled trial

Objective: To determine the effect of activity-based mirror therapy (MT) on motor recovery and gait in chronic poststroke hemiparetic subjects.

Design: A randomised, controlled, assessor-blinded trial.

Setting: Rehabilitation institute.

Participants: Thirty-six chronic poststroke (15.89?±?9.01 months) hemiparetic subjects (age: 46.44?±?7.89 years, 30 men and functional ambulation classification of median level 3).

Interventions: Activity-based MT comprised movements such as ball-rolling, rocker-board, and pedalling. The activities were provided on the less-affected side in front of the mirror while hiding the affected limb. The movement of the less-affected lower limb was projected as over the affected limb. Conventional motor therapy based on neurophysiological approaches was also provided to the experimental group. The control group received only conventional management.

Main outcome measures: Brunnstrom recovery stages (BRS), Fugl-Meyer assessment lower extremity (FMA-LE), Rivermead visual gait assessment (RVGA), and 10-metre walk test (10-MWT).

Results: Postintervention, the experimental group exhibited significant and favourable changes for FMA-LE (mean difference?=?3.29, 95% CI?=?1.23–5.35, p?=?.003) and RVGA (mean difference?=?5.41, 95% CI?=?1.12–9.71, p?=?.015) in comparison to the control group. No considerable changes were observed on 10-MWT.

Conclusions: Activity-based MT facilitates motor recovery of the lower limb as well as reduces gait deviations among chronic poststroke hemiparetic subjects.     

A study on the association of psychiatric diagnoses and childhood adversities with suicide risk

Background: In addition to psychiatric disorders, childhood adversities may increase the risk of suicidal behavior. In previous studies, the effects of clinical co-morbidity and overlap of childhood adversities has rarely been taken into account.

Aim: The study aims to search associations of psychiatric diagnoses and childhood adversities and trauma (CAT) with suicide risk.

Methods: Altogether 415 adult patients attending primary and psychiatric outpatient care filled in the Trauma and Distress Scale, including assessment of five core CAT domains (emotional, physical and sexual abuse, and emotional and physical neglect). The study patients’ current psychiatric disorders and suicide risk were assessed by the Mini International Neuropsychiatric Interview.

Results: Age, poor perceived health, poor social support, current psychiatric treatment, all psychiatric disorders, except hypomania, emotional and physical abuse, and emotional neglect did associate significantly with suicide risk. Number of psychiatric disorders and CAT domains had dose-dependent effects on suicide risk. In multivariate analysis, current psychiatric treatment, current and life-time major depression, social phobia, alcohol, and drug dependency, as well as emotional abuse had direct associations with suicide risk. In females, manic disorders and drug dependence, and in males, dysthymia, social phobia, and emotional abuse associated with suicide risk.

Conclusions: Psychiatric disorders and most CAT domains associate with suicide risk. However, when the effect of co-morbidity and overlap of CAT domains is controlled, major depression, social phobia, alcohol, and drug dependency and emotional abuse seem to increase the risk of suicide. The risk profile varies between the genders.     

Exploring dimensions of social support and resilience when providing care at the end of life: a qualitative study

Background: Research shows that formal and informal social support can facilitate resilience in carers. There is a paucity of research exploring social support and resilience amongst recently bereaved informal carers.

Aim: To examine how the presence or absence of distinct dimensions of social support facilitate or hinder resilience in recently bereaved informal carers.

Participants: 44 bereaved carers, who had been identified by GP as ‘main carer’ of someone recently deceased (3–12 months), aged between 38 and 87 years old (mean= 67).

Methods: Thematic analysis then the Ecological Framework of Resilience as an organisational tool to develop overarching themes in the data. We used the Sherbourne and Stewart model to identify social support that was lacking as well as social support that was present.

Results: A range of social support types were identified. There was an emphasis on the importance of relationships with both health professionals and family members, including the care recipient. However, social support was not necessary for resilience if the participant had other resources.

Conclusions: Social support for carers providing end of life care is almost exclusively based around end of life care ‘work’. In comparison to other research our study suggests that relationships with family and health professionals are paramount. Multidimensional support is needed for carers to enhance their resilience.     

Pharmacogenetics and levodopa induced motor complications

Aim: L-dopa remains the most effective symptomatic therapy for Parkinson's disease (PD) but unfortunately, its chronic use is often associated with motor complications. This review highlights the importance of pharmacogenetics in an individualised PD therapeutic approach.

Material and Methods: review of the literature was done.

Results: PD patients show remarkable heterogeneity in their response to L-dopa and this profound interindividual heterogeneity suggests that there is a genetic predisposition.

Conclusions: The impact of the genetic makeup of every individual on PD treatment appears to be of great importance in order to achieve not only the optimum therapeutic effect, but also with minimal side effects.     

Screening Adherence for Depression Post Stroke: Evaluation of Outpatients,a London Experience (SAD PEOPLE)

Background: Post stroke depression (PSD) is common, and the transition home following discharge may be especially challenging for stroke survivors.

Objectives: This study aimed to determine how well specific Canadian Best Practice Recommendations for PSD screening were adopted within a stroke rehabilitation outpatient clinic before and after the utilization of a standardized clinical form.

Methods: Practices were evaluated through retrospective chart review before and after the implementation of the standardized form which cued physicians to administer the Patient Health Questionnaire 9 (PHQ-9) at the first outpatient visit. Participants included those aged ≥18 years with a primary diagnosis of stroke.

Results: One hundred thirty-five subjects’ charts were reviewed. Form implementation was associated with increased rates of PSD screening (93.8% versus 0%) and charting regarding mood (55.4% versus 15.7%).

Conclusion: This study highlights the frequency of depressive symptoms in an outpatient cohort and demonstrates how screening rates can be improved by using a standardized form. Routine PHQ-9 completion at the first outpatient visit was associated with more physician–patient discussion and documentation regarding mood.     

A how-to guide to aphasia services: celebrating Professor Linda Worrall’s contribution to the field

Background: This article recognises Professor Linda Worrall’s contribution to aphasiology and discusses research themes which have grown from her work.

Aims: To review, summarise, and discuss literature relating to four themes which have emerged from the work of Professor Worrall: (1) Research capacity building; (2) Implementation of research evidence in clinical practice; (3) Meaningful outcome measurement; and (4) Improvement of psychological and emotional outcomes.

Main contribution: A review of the literature, with examples of practical applications.

Conclusions: The work of Professor Worrall has greatly influenced the field of aphasia; her legacy is the research capacity she has built in Australia and around the world.     

An elderly patient with Alzheimer’s disease,normal pressure hydrocephalus and traumatic brain injury: presented with behavioral symptoms similar to behavioral variant frontotemporal dementia

Objective: Traumatic brain injury (TBI) is nondegenerative insult to brain from external mechanical forces. It may cause cognitive impairment, psychological problems in the long period. Besides traumatic brain injury also induces neuroinflammation and neurodegeneration process, and increases risk of dementia. It may cause various psychiatric complications such as depression, posttraumatic stress disorder, generalized anxiety disorder, and other cognitive and behavioral sequela according to site of involvement in the brain.

Methods: We report a patient who has behavioral symptoms, amnesia and gait apraxy after TBI. Patient's symptoms were similar to behavioral variant Frontotemporal Dementia (bv FTD).

Results: After detailed neurocognitive and radiologic evaluation he was diagnosed with Normal Pressure Hydrocephalus (NPH), and Alzheimer's Disease (AD) following TBI.

Conclusion: Comprehensive geriatric assessment, including detailed radiological examinations, if it is necessary, is recommended for the optimum management of elderly patients with cognitive and psychosocial problems in order to avoid misdiagnosis and inappropriate treatment.     

French translation and validation of a fragile X syndrome screening checklist

Background: Fragile X syndrome (FXS) is the most common cause of inherited intellectual disability among men. This syndrome is frequently underdiagnosed in adults. The aim of this study was to develop and validate a French translation of the screening checklist Fragiele-X screeningslijst.

Method: The validation sample for the translated checklist included 22 pairs of men between the ages of 18 and 52, matched by age and degree of intellectual impairment.

Results: The translated checklist achieved coefficients of 0.92 for internal consistency, 0.90 for test-retest reliability and 0.65 for inter-rater reliability. These psychometric properties are commensurate with those of the original checklist.

Conclusion: Therefore, the translated checklist developed in this study can be considered a valid screening instrument for the detection of FXS in men with intellectual disabilities.

Abbreviations: FXS: fragile X syndrome; FMR1: fragile X mental retardation 1 (gene)     

Repetitive transcranial magnetic stimulation (rTMS) for depression: outcomes in a United Kingdom (UK) clinical practice

Objective: The aim of this paper is to present the outcomes data from the largest United Kingdom’s (UK) National Health Service (NHS) clinical rTMS service treating treatment resistant depression (TRD).

Methods: The study was a retrospective investigation of routinely collected data on patients receiving rTMS between 2015 and 2017. Measures used were the clinician-rated Clinical Global Impression (CGI) and Hamilton Depression Rating Scale (HAM-D), and patient rated Beck Depression Inventory (BDI). The outcome data of 73 patients with TRD were analysed. The sample included patients with co-morbid psychiatric diagnosis.

Results: Response and remission rates, respectively, were 40.4% and 25.5% for the HAM-D; 35.6% and 20.8% for the BDI; and 51.1% and 52.1% for the CGI. Effect sizes were medium (0.54, 0.52 and 0.56, respectively).

Conclusions: The results show that a UK-based clinical service achieves similar results to those published internationally and that clinical rTMS can have significant impact on symptoms of depression in many patients with TRD. Health services are under pressure to make financial savings, investment in rTMS could reduce the long-term treatment costs associated with TRD.     

A Note on the “One Case per Stagger Position” Character of Common Multiple-Baseline Intervention Designs

Purpose: To overcome the constraint of common multiple-baseline designs that only one case per stagger position is permitted.

Methods: Three alternative strategies for assigning more than one case to each stagger position are examined.

Results: The three recommended strategies achieve the objective while maintaining the study’s internal and statistical-conclusion validities.

Conclusions: ExPRT, a freely available Excel-based randomization-test package, can be used to assist in both the design and statistical analysis associated with each of the strategies.     

Abnormalities in P300 components in depression: an ERP-sLORETA study

Background: Alterations in P300 components occur in depressed patients, but the brain regions contributing to these changes remain unclear.

Aims: Thus, the aim of the present study was to examine the underlying neural activation of P300 components in patients with depression to explore brain regions related to depression.

Methods: P300 components were evoked by an oddball auditory paradigm and recorded from 30 patients with current depression, as well as 30 age-, gender-, and education level-matched healthy controls. The standardized Low-Resolution Brain Electromagnetic Tomography (sLORETA) method was used to explore the source activation of P300 components.

Results: Compared with healthy controls, depressed patients tended to exhibit lower P200 and P300 amplitudes and prolonged P300 latency. In depressed patients, P200 source activations were reduced in the right insula, right precentral gyrus, left anterior cingulate, medial frontal gyrus, superior frontal gyrus, and middle frontal gyrus. Decreased source activations of P300 were identified in the right insula, postcentral gyrus, superior temporal gyrus, inferior parietal lobule, transverse temporal gyrus, cingulate gyrus, precentral gyrus, middle frontal gyrus, superior frontal gyrus, medial frontal gyrus, and paracentral gyrus.

Conclusions: Extensive dysfunction over the right hemisphere and bilateral prefrontal dysfunction may be involved in the pathophysiology of depression.     

Unmet care needs,care provision and patient satisfaction in patients with a late life depression: a cross-sectional study

Background: Research has shown that some 30% of total care needs in people with late-life depression (LLD) are unmet. It is not known to what extent patients actually don't receive any care for these needs or consider the care to be insufficient and their satisfaction with the provided care.

Aim: The aim of this study is to obtain insight into the care provided in relation to the reported unmet care needs and satisfaction with the total care provided is examined.

Method: A cross-sectional study of 99 people with LLD in an ambulatory setting.

Results: In 67% of patients, at least one unmet need was ascertained. In most cases (80%) care was actually provided for those needs by professionals and/or informal caregivers. Patients were satisfied with the care delivered for 81% of the reported care needs. Satisfaction was lowest for social care needs (67%). For six specific care needs it was demonstrated that dissatisfied patients were significantly more depressed than satisfied patients.

Conclusion: Even though patients might receive care for certain needs, this does not mean that their needs are met. A substantial proportion of patients with LDD feel that they need additional help for unmet needs.     

Pain inconsistency and sleep in mid to late-life: the role of depression

Objectives: Inconsistency in pain may lead to depression, which may then influence sleep. Thus, the purpose of this study was to examine whether depression mediates the relationship between day-to-day inconsistency in pain and sleep in middle aged to older adults.

Methods: Baseline measures from the Active Adult Mentoring Project were used for secondary data analysis. Participants included 82 adults in mid- to late-life. Pain was assessed for seven consecutive days on an 11-point Likert-scale, with pain inconsistency defined as the seven-day individual standard deviation. A self-report daily diary was used to assess sleep efficiency (SE), total wake time (TWT), total sleep time (TST), and sleep quality (SQ), and depression was assessed using the BDI-II.

Results: Mediation analyses revealed that depression partially mediated the relationship between pain inconsistency and SE, TWT, and SQ but not TST.

Conclusions: Results indicate that depression may be an important factor through which pain inconsistency influences sleep. Although further research is warranted, these preliminary findings suggest that intervening on both pain inconsistency and depression may be one way to improve sleep in older adults.     

Socio-economic predictors of depressive symptoms around old age retirement in Swedish women and men

Objectives: To estimate trajectories of depression around old age retirement in Swedish women and men and examine if socio-economic status predicted the trajectories

Methods: The analytic sample comprised 907 women and 806 men from the Swedish Longitudinal Occupational Survey of Health. B-spline smoothers and group-based trajectory modelling were used to identify groups of individuals with similar trajectories of depressive symptoms around retirement. Multinomial regression analyses were conducted to investigate if socio-economic factors were associated with odds of belonging to trajectory groups with higher depression scores.

Results: Four depressive symptoms trajectories were identified in both genders, all showing similar symptom levels across the retirement transition. Low levels of depressive symptoms were observed in the three largest groups. In the last trajectory group among women (2.5%) depression scores were moderate to severe and among men (3.3%) depression scores were persistent moderate. Higher educational level and lower subjectively rated social status were associated with higher odds of belonging to trajectory groups with higher levels of depressive symptoms in both genders.

Conclusion: Retirement transition was not associated with symptoms of depression. Higher educational level and lower subjective social status may predict higher depressive symptom levels the years around old age retirement.     

Perceptions of psychiatry residents and non-residents on training needs and care related to patients with intellectual disability and mental health problems: A study from Singapore

Background: People with intellectual disability (ID) have higher risk of mental morbidity and specialised training may be required in their management. We explored the training needs and knowledge as well as perceptions of care of such patients among residents and non-residents working in psychiatry.

Method: The study was conducted as an anonymous survey. Questionnaires were sent to all residents and non-residents at a large psychiatric hospital in Singapore.

Results: Forty-eight out of the 76 questionnaires sent out were returned. All participants responded that postgraduate training was required in the area of ID and mental health and according to the majority, available training was inadequate. Over 90% believed that people with ID were vulnerable to exploitation and they should be under a specialist team.

Conclusion: Efforts should be made to include specialist training in psychiatry of ID in the Singapore psychiatry curriculum to enhance the knowledge and expertise of psychiatrists in this field.     

Choosing among second-generation antidepressant treatments for depressed patients with cardiac diseases

Objectives: The present paper aimed to assist physicians in the accurate choice among second-generation agents (SGAs) for patients with cardiovascular disease (CVD).

Methods: We reviewed the published pharmacokinetic (PK) and pharmacodynamic (PD) clinical data that report potential -or absence of- drug interactions between second-generation agents (SGAs) and CVD drugs most commonly used in cardiology, including antiplatelet drugs and anticoagulants, statins, beta-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics and the antiarrhythmic drugs amiodarone and digoxin.

We also reviewed the cardiovascular safety profile that has been published for each class of SGAs and side effects reported by patients with CVD.

Results: Most relevant PK/PD data about SGAs and CVD drugs are based on small studies or detailed case reports. In many cases, the drug interactions are at most assessed in healthy volunteers so that the clinical relevance of findings needs further investigation in patients with CVD. Case reports of serious, sometimes fatal reactions due to concomitant administration of certain drugs require careful consideration.

The major cardiac side effects of SGAs include HR increase, postural hypotension and slight prolongation of the intraventricular conduction time and QT interval. On normal dosage of antidepressants, both advanced heart block and ventricular arrhythmias could occur in patients with severe heart disease, together with clinically important loss of myocardial contractile force.

Conclusions: Data reported in the present review should help physicians about their decision-making processes that govern SGAs use in CVD patients.     

Guilt after placement questionnaire: a new instrument to assess caregiver emotional functioning following nursing home placement

Objective: Guilt is a core feature of dementia caregivers’ experiences following placement. This study describes and validates a new assessment tool for monitoring caregiver adjustment after placement.

Methods: Forty-six items addressing ambivalence and guilt about placement were tested with 170 dementia caregivers (M age = 56.79, SD = 13.19; 69.4% female; 54.7% adult child).

Results: Using principal axis factor analysis, 10 items were retained that showed acceptable internal consistency (Cronbach's alpha of 0.92). Construct validity was established in a subset of the sample (n = 53) with measures of depression (r = 0.53), burden (r = 0.48), conflict with staff (r = 0.47), and well-being (r = ?0.30).

Conclusions: This scale may be used to identify caregivers at risk for adjustment problems following placement and to monitor adjustment over time.     

Estimation of skeletal muscle mass in patients with spinocerebellar ataxia type 3 and 10

Background: Neurodegenerative diseases may progress to a level in which patients present spontaneous weight loss, resulting in increased falls and functional disabilities when the disease is associated with muscle mass depletion.

Objective: Evaluate the muscle compartment in patients presenting spinocerebellar ataxia (SCA) type 3 and 10.

Methods: Forty-six patients presenting SCA type 3 and 10 were assessed and 76 volunteers were selected to the control group. In order to evaluate the muscle compartment, muscle mass anthropometric measurements were assessed and total skeletal muscle mass calculated through a predictive equation.

Results: Women with SCA3 presented greater weight loss and muscle mass reduction compared to those with SCA10 and the control group. Among the predictive measurements, calf muscle circumference showed a more significant correlation with total skeletal muscle mass (p = 0.718).

Conclusion: Patients presenting both types of ataxia did not show severe depletion in their nutritional status; however, those with SCA3 displayed greater weight loss and muscle mass reduction compared to the SCA10 group.     

Association between prescribed antidepressants and other prescribed drugs differ by gender: a nationwide register-based study in Sweden

Background: People with depression are prescribed more drugs than people in general, partly due to comorbidity with other conditions. However, little research has been done on depression-related drug use from a gender perspective.

Aim: Examine the association between antidepressants, other types of prescribed drugs, and polypharmacy, by gender.

Methods: Data on drugs dispensed October to December 2016 to all Swedish citizens aged 18–84 years were collected from the Swedish prescribed drug register. Logistic regression analyses were performed to examine the associations between antidepressants and other drugs, by gender.

Results: For both men and women, associations were found between antidepressants and drugs for alimentary tract problems, respiratory problems, blood, nervous system, analgesics, and polypharmacy. However, for women, but not men, associations were also found for drugs for diabetes, musculoskeletal problems, dermatological problems, and systemic hormones.

Conclusions: Associations were found between antidepressants and many other types of drugs for both men and women; indicating comorbidity between depression and other conditions. Further, some of the associations between antidepressants and other drugs were found to be specific among women. Whether this indicates that men and women differ in comorbidity between depression and other conditions cannot be concluded based on this cross-sectional study. However, comorbidity impairs the possibility of recovery; in the somatic condition as well as the depression. Thus, physicians need to be aware that the association between antidepressants and other types of drugs are more common among women than men.     

Using photographs to explore self-understanding in adolescent boys with an autism spectrum condition

Background: Research evidence suggests that self-understanding is likely to be limited in individuals with autism.

Method: Photo-elicitation interview was used to explore self-understanding in five adolescent boys diagnosed with an autism spectrum condition.

Results: An interpretative phenomenological analysis yielded three superordinate themes: self in action, self extended in time and self in relation to others. These themes captured how participants understood themselves in terms of their actions and abilities, in the context of their past and future and in relation to others.

Implications: The findings suggested that self-understanding is informed by relationships with parents, self-other comparisons and by reflecting on past and future selves, as well as on activities engaged in. Photo-elicitation was effective in engaging participants with the research process.