Intrathecal baclofen in subjects with spastic hemiplegia: assessment of the antispastic effect during gait

OBJECTIVE: To determine whether leg muscle stiffness is measurably reduced after intrathecal baclofen (ITB) in subjects with spastic hemiplegia. DESIGN: Nonrandomized trial. SETTING: Inpatient multidisciplinary rehabilitation unit in France. PARTICIPANTS: Seven consecutive subjects with spastic hemiplegia having Ashworth Scale scores for their quadriceps and triceps greater than 2. INTERVENTION: Subjects were given ITB by lumbar puncture after a dose-selecting test period. MAIN OUTCOME MEASURES: Triceps and quadriceps Ashworth scores, gait analysis at preferred and maximal speed measured by a motion analysis system with 2 forceplates, and electromyographic recording of leg muscles before and 4 hours after ITB. The slopes of the moment-angle curves were measured on the hemiplegic side at the onset of ankle and knee flexion to assess muscle stiffness during walking. Pre- and post-ITB spatiotemporal, kinetic, and kinematic data were compared by using a nonparametric test (Wilcoxon signed-rank test). RESULTS: Ashworth scores of the quadriceps and triceps of all subjects decreased significantly after ITB. Maximal walking speed increased significantly, with a significant increase in stride length, but the preferred walking speed was unchanged. Minimal knee extension and maximal ankle flexion were the only kinematic data significantly different (increased) after ITB. The slope of the ankle moment-angle curve decreased significantly after ITB at preferred gait speed; it also decreased at maximal gait speed in all but 1 subject. Of the 4 available moment-angle curves, 3 showed decreased knee extensor muscle stiffness. The duration of the bursts of spastic muscles decreased after ITB. CONCLUSION: Acute ITB improved walking and reduced muscle stiffness at both the ankles and knees on the spastic hemiplegic side of our subjects. Electromyographic findings suggest that some of the post-ITB reduction in muscle stiffness might be attributed to decreased spasticity.     

Determinants of walking function after stroke: differences by deficit severity

OBJECTIVES: To investigate the relationship of cardiovascular fitness (Vo(2)peak), neurologic deficits in balance and leg strength, and body composition to ambulatory function after stroke and to determine whether these relationships differ between those with milder versus more severe gait deficits. DESIGN: Cross-sectional correlation study. SETTING: Outpatient clinic of an academic medical center. PARTICIPANTS: Seventy-four people (43 men, 31 women; mean age +/- standard deviation, 64+/-10y) with chronic hemiparetic stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Thirty-foot (9.1-m) walk velocity, 6-minute walk distance, Vo(2)peak, Berg Balance Scale score, bilateral quadriceps eccentric torque, total and regional lean mass, and percentage of fat mass. RESULTS: Short-distance walking correlated significantly with cardiovascular fitness, balance, paretic leg strength, nonparetic leg strength, percentage of body fat, and paretic lean mass but not with nonparetic lean mass. Long-distance walking correlated significantly with cardiovascular fitness, balance, paretic leg strength, nonparetic leg strength, and paretic lean mass but not with percentage of body fat or nonparetic lean mass. Stepwise regression showed that cardiovascular fitness, balance, and paretic leg strength were independently associated with long-distance walking (r(2)=.60, P<.001). Variance in long-distance walking was largely explained by balance for those who walked more slowly (<.48m/s) for short distances (r(2)=.42, P<.001) and by cardiovascular fitness for those who walked more quickly (>.48m/s) for short distances (r(2)=.26, P=.003). CONCLUSIONS: Short-distance walking after stroke is related to balance, cardiovascular fitness, and paretic leg strength. Long-distance walking ability differs by gait deficit severity, with balance more important in those who walk more slowly and cardiovascular fitness playing a greater role in those who walk more quickly. Improved understanding of the factors that predict ambulatory function may assist the design of individualized rehabilitation strategies across the spectrum of gait deficit severity in those with hemiparetic stroke.     

偏瘫功能康复的评价

根据Barthel指数评价将491例偏瘫病人分为依赖组和自理组,并且观察康复前后的Barthel指数及活动能力变化情况,结果表明自理组病人的Barthel指数和活动能力较依赖组明显改善,分别增加100％和77％(P<0.01),康复频度减少9.1％(P>0.05),康复程度下降6.6％(P<0.001)。作者认为,偏瘫病人通过严格的康复医学检查,早期积极康复医疗,根据个体Barthel指数评价康复程度,是一种比较全面而切合实际的方法,从生物-心理-社会的综合医学模式出发,对偏瘫病人进行功能康复评价是有益的。     

偏瘫肢体功能锻炼对脑卒中后患者康复评定分析

目的：探讨早期功能锻练对脑卒中后偏瘫患者肢体功能恢复的疗效。方法：选取2006年1月至2008年1月间在我院住院的脑卒中偏瘫患者84例,随机分为康复组和对照组,康复组给予早期肢体功能锻炼,对照组给予常规的医护措施。结果：两组治疗后神经功能缺损程度评分均优于入院时,两者比较差异均具有统计学意义（P〈0．05）;康复组入院2周、4周及出院时神经功能缺损程度评分均优于对照组,两者比较差异具有统计学意义（P〈0．05）;治疗后康复组患者Brunnstrom分级上下肢I级例数明显少于对照组,两者比较差异具有统计学意义（P〈0．05）。结论：早期肢体功能锻炼能明显地改善脑卒中偏瘫患者的肢体功能,并能提高日常生活能力,值得应用。     

早期康复治疗在急性脑梗塞患者中的应用研究

目的:探讨早期康复治疗急性脑梗塞的疗效和可行性,以及对血清中脑源性神经营养因子水平的影响.方法:70例急性脑梗塞患者随机分为康复组和对照组各35例,于治疗前和治疗后1个月、3个月,对两组患者进行运动功能评定,采用简式Fugl-Meyer运动功能评分法;日常生活活动能力评定,采用Barthel指数;观察记录肩手综合征发生...     

神经功能重建康复仪治疗对脑卒中后偏瘫肢体运动功能的影响

①目的探讨神经功能重建康复仪治疗对脑卒中后运动功能障碍的影响。②方法将60例脑卒中后偏瘫患者随机分为观察组和对照组,每组各30例。观察组采用神经功能重建康复仪治疗结合康复运动训练,对照组仅单纯使用康复运动训练。两组患者常规神经内科治疗及护理。治疗前后均采用Lovett徒手肌力测定和改良巴氏指数（BI）评定日常生活能力。③结果治疗1个月和3个月后观察组偏瘫肢体肌力和BI指数明显改善,与对照组比较差别有显著性意义。④结论神经功能重建康复仪治疗对脑卒中后偏瘫肢体的康复效果优于单纯康复训练。     

Modular structure of awareness for sensorimotor disorders: evidence from anosognosia for hemiplegia and anosognosia for hemianaesthesia

In the present paper, we shall review clinical evidence and theoretical models related to anosognosia for sensorimotor impairments that may help in understanding the normal processing underlying conscious self-awareness. The dissociations between anosognosia for hemiplegia and anosognosia for hemianaesthesia are considered to give important clinical evidence supporting the hypothesis that awareness of sensory and motor deficits depends on the functioning of discrete self-monitoring processes. We shall also present clinical and anatomical data on four single case reports of patients selectively affected by anosognosia for hemianaesthesia. The differences in the anatomical localization of lesions causing anosognosia for hemiplegia and anosognosia for hemianaesthesia are taken as evidence that cerebral circuits subserving these monitoring processes are located in separate brain areas, which may be involved both in the execution of primary functions and the emergence of awareness related to the monitoring of the same functions. The implications of these findings for the structure of conscious processes shall be also discussed.     

Differentiation of hand posture to object shape in children with unilateral spastic cerebral palsy

Quantifying hand-shaping in children with unilateral spastic cerebral palsy (USCP) is the first step in understanding hand posture differentiation. To quantify this ability and determine how hand posture evolves during reach toward various object shapes in children with unilateral spastic cerebral palsy (USCP), 2 groups of children (10 typically developing, and 10 USCP, ages 6–13) were studied in a single-session cross-sectional study. Subjects grasped rectangular, concave, and convex objects with each hand. Metacarpal and proximal interphalangeal joint finger flexion and finger abduction angles were calculated. The extent to which hand posture reflects object shape was calculated using a “visuomotor efficiency (VME) index” (a score of 100 reflects perfect discrimination between objects). A mixed design ANOVA with repeated measures on time was used to compare the VME between groups. Children with USCP demonstrated a lower VME than controls in the affected hand, indicating less effective hand-shaping; p < .01. There was also a difference between groups in the evolution of VME throughout reach; p < .01. No difference in hand-shaping in the less affected hand in USCP was observed. Analysis of joint angles at contact and VME throughout reach demonstrated that children with USCP differentiated their hand posture to objects of different shapes, but demonstrated deficits in the timing and magnitude of hand-shaping isolated to the affected side. The present study suggests it may be important to consider the quality of hand activity using quantitative approaches such as VME analyses. Rehabilitation approaches that target these deficits to improve joint mobility and motor control are worth testing.     

规范三级康复治疗对脑卒中患者生存质量的影响

目的 探索规范的三级康复治疗后，脑卒中偏瘫患者生存质量的改善规律。方法 按分层区组随机化的方法，将82例脑卒中患者随机纳入到康复组和对照组，康复组在常规内科治疗基础上给予规范的三级康复治疗，对照组仅予以一般的常规内科治疗，分别于入选时，病后1个月末、3个月末和6个月末采用生存质量测定量表简表进行评测。结果 对照组2例死亡，康复组没有死亡病例。康复组患者康复治疗后各阶段生存质量量表中的生理健康、心理状态、社会关系、与周围环境的关系、自身生存质量的总的主观感觉、自身健康状况的总的主观感受和综合自评分等项目的得分明显高于对照组。2组患者的生存质量存在明显差异，随着时间的推移，生存质量的各项评分有着明显的改善（除外社会关系项目）。发病后前3个月生存质量改善最为明显，后3个月生存质量改善速度明显减慢、幅度明显减小。结论 规范三级康复治疗能够明显改善脑卒中患者的生存质量，早期患者生存质量改善较为快速明显，后期生存质量改善速度明显减慢。