Background and Objective. The authors recently found that grasping was not relatively more disrupted than reaching in people with acute hemiparesis. They now extend this work to the recovery of reach ...versus grasp.
Methods. Hemiparetic subjects were tested acutely, after 90 days, and then after 1 year poststroke, and a control group was evaluated once. Using kinematic techniques, subjects were studied performing reach and reach-to-grasp movements. The authors quantified 3 characteristics of performance for each movement: speed, accuracy, and efficiency, where an efficient movement was defined as a movement directly to the target without extraneous or abnormally circuitous movements. To evaluate the relative deficits and recovery in reach versus grasp, performance measures were converted to z scores using control group means and standard deviations.
Results. The authors’ results showed that, starting with small deficits in speed acutely, both reach speed and grasp speed improved over time. Deficits in accuracy were greater in the reach than the grasp acutely, and these deficits lessened such that by the 90-day time point, the relative accuracy of the 2 movements was the same. In contrast, deficits in efficiency were greater in the grasp than the reach acutely, and grasp efficiency did not recover. The majority of recovery in reaching and grasping occurred by the 90-day time point, with little change occurring between the 90-day and 1-year time points.
Conclusions. The authors hypothesize that, in chronic hemiparesis, purposeful movements requiring distal control may be more impaired than purposeful movements requiring proximal control, not because of the initial lesion, but because, over the course of recovery, spared components of the descending motor systems may be able to compensate for the accuracy deficits in reaching (proximal control) but not the efficiency deficits in grasping (distal muscular control).
To determine the relationships between sensorimotor impairments and upper extremity reaching performance during the acute phase of stroke and to determine which, if any, measures of sensorimotor ...impairment can predict variance in reaching performance during this phase. Methods. Sensorimotor impairments of upper extremity (UE) strength, active range of motion, isolated movement control, light touch sensation, joint position sense, spasticity, and shoulder pain were evaluated in a group of 46 individuals with acute hemiparesis (mean time since insult = 9.2 days). Subjects performed a reaching task to a target placed on their affected side. Three-dimensional kinematic analyses were used to assess reaching speed, accuracy, and efficiency. Forward stepwise multiple linear regression analyses were used to determine which impairment was the best predictor of variance in reaching performance. Results. Measures of UE strength predicted the largest proportion of variance in the speed, accuracy, and efficiency of forward reaching. Isolated movement control, somatosensory deficits, and elbow spasticity predicted smaller amounts of variance in reaching performance. Conclusions. The authors’ data show that deficits in strength appear to be the most influential sensorimotor impairment associated with limited reaching performance in subjects with acute hemiparesis.
The purpose of this case report is to describe the classification, intervention, and outcomes for a patient with lumbar rotation with flexion syndrome.
The patient was a 22-year-old man with a ...medical diagnosis of low back strain. Impairments in lumbar flexion and right rotation and lateral bending were identified. Daily activities and positions associated with these actions were associated with increased low back pain (LBP). Instruction focused on modifying lumbar rotation and flexion movements and alignments in daily activities. Exercises to address the direction-specific impairments were prescribed.
The patient participated in 4 visits and completed a questionnaire 1 year after intervention. The patient reported a decrease in symptoms, disability, and frequency of recurrences.
Repetition of specific strategies (alignment and movement) during activities may result in specific impairments that contribute to LBP. Modification of the strategies and exercises to change contributing factors are proposed to help alleviate symptoms, disability, and recurrences.
A decreased gait speed in older adults can lead to dependency when the individuals are no longer able to participate in activities or do things for themselves. Thirty-seven senior apartment residents ...(31 females; Mean age = 80.6 years; SD = 8.9) with lower extremity pain/stiffness participated in a feasibility and preliminary efficacy study of 12 weeks (24 sessions). Healthy-Steps dance therapy compared to a wait-list control group. Small improvements in gait speed (ES = 0.33) were noted for participants completing 19–24 dance sessions. Improvements in gait speed measured by a 10 Meter Walk Test (0.0517 m/s) exceeded 0.05 m/s, a value deemed to be meaningful in community dwelling older adults. These feasibility study findings support the need for additional research using dance-based therapy for older adults with lower extremity pain.
To evaluate objectively the effectiveness of current surgical management of displaced acetabular fractures. To provide insight into how these evaluation methods can be used to identify areas in which ...improvements in surgery and rehabilitation can be pursued to improve patient outcomes.
Consecutive case series.
University medical center.
Fifteen patients were studied, each with an isolated, displaced acetabular fracture treated with a Kocher-Langenbeck approach.
Primary outcome measures included hip muscle strength, including work (Joules/minute) and maximum torque (30 degrees/second) for abductors/adductors and flexors/extensors. Gait analysis of patients and able-bodied cohorts, including stride length, speed, and cadence, were also assessed. Motion analysis during gait was also studied for each body segment, including the trunk, pelvis, hip, knee, and ankle, in the sagittal, frontal, and axial planes. Motion data for the affected side was compared with motion data for the unaffected side, and linear gait findings for the study patients were compared to able-bodied cohorts. An assessment of clinical outcome was performed by completion of a validated Musculoskeletal Function Assessment (MFA) questionnaire and the were results correlated with muscle strength and gait analysis. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, the presence and severity of heterotopic ossification at the time of the most recent follow-up, and passive range of motion of the affected and unaffected hips.
No statistical differences in muscle strength for each of the major muscle groups were found when the affected limb was compared with the unaffected limb. No statistical differences were found between the study patients and the able-bodied cohorts with regards to stride length, gait speed, and cadence. The only significant difference found in body segment position was trunk inclination. When the study patients were compared with able-bodied cohorts, the patients tended to walk with greater forward inclination of their trunks; this was true for all phases of gait. Total MFA scores averaged 22 (range, 0-57). Patients could be separated into two separate groups based on their total MFA score. One group (n = 6) had an average MFA score of 7 (range, 0-10), while a second group (n = 9) had an average MFA score of 32 (range, 12-57). The scores of study patients as a whole, and those of each individual group of patients, were compared with known MFA scores for nonpatients and patients in the Orthopaedic Trauma Association/Association for the Study of Internal Fixation (OTA/AO) injury group (hip and thigh). When the muscle strengths of these two groups of patients were compared, all hip flexion and extension variables were significantly weaker in the group with an average MFA score of 32, whereas none of the gait variables were different between the two groups. At an average follow-up of 24 months, seven patients had an excellent radiographic grade, four patients had a good grade, two patients had a fair grade, and two patients had a poor grade. These radiographic grades were in contrast to achieving an anatomic reduction in eleven patients, a satisfactory reduction in three patients, and an unsatisfactory reduction in one patient. Heterotopic ossification was found in eight patients, four patients had Grade 1, and four patients, had Grade 2. No statistically significant differences were observed when each MFA group was compared with each of these radiographic variables. Passive hip range of motion was not statistically different when the affected hip was compared with the unaffected hip.
Standardized muscle strength determination, gait, and motion analysis, and completion of an MFA questionnaire provided a thorough and revealing evaluation of patients who have undergone open reduction and internal fixation (ORIF) of a displaced acetabular fracture. Minimal alterations in body posture and affected limb motion were present in patients displaying relatively normal gait parameters, including stride length, speed, and cadence. Despite dissection of the hip musculature during surgery, normal muscle strength recovery was possible after operative repair of these acetabular fractures. However, functional outcome, as determined by MFA scores, was considerably poorer in those patients with significantly weaker hip flexion and extension strength, compared with those of patients with more desirable MFA scores. Based on the current data, it appears that the use of these and similar evaluation instruments can allow determination of factors that negatively affect outcome (hip flexion and extension strength), which otherwise may remain unknown. It is possible that identification and treatment of these factors will improve the quality of life for patients after this type of injury.
This was a prospective analysis of adult spinal deformity patients having fusions from the thoracic spine down to L5 or the sacrum. Gait analysis was performed before surgery and 1 and 2 years ...postoperatively, as was questionnaire analysis.
To compare the preoperative and postoperative gait of revision and primary patients having long fusions to the distal lumbar spine or sacrum with that of a group of able-bodied adults. The experimental hypothesis was that both patient groups would have significantly compromised preoperative gait and gait endurance compared to the able-bodied group and that significant changes would be noted in both groups at 1 and 2 years postoperation.
Spinal reconstructive surgery is often performed on adults with progressive lumbar spinal deformities. These patients can be divided into two major groups. The first are those patients who have degenerative changes superimposed on idiopathic scoliosis (primary patients) without previous operative treatment; the second are those patients who have already had a long fusion to L4, L5, or the sacrum (revision patients).
Twenty-nine women participated in the investigation (8 primary, 12 revision, 9 able-bodied controls). A gait analysis was performed before surgery and 1 and 2 years postoperation. Walking endurance (time) was estimated from a submaximal graded treadmill exercise test. Motion variables describing the gait of the subjects, as well as gait speed, were determined. The SRS, Oswestry questionnaires, and an analog pain scale were also administered.
The primary group showed no adverse changes in lower extremity kinematics after surgery, and their gait speed improved such that it was not significantly different from the able-bodied group at 2 years postoperation. The revision group displayed lower extremity gait kinematics that were significantly different from the able-bodied group before surgery, but were no longer different from the able-bodied 2 years after surgery. They also had a significant increase in gait endurance. Questionnaire data indicated significant improvements for both groups after surgery.
Objective gait data quantifying the efficacy of reconstructive spinal surgery in both primary and revision patients indicated improved gait. Gait endurance was improved in the revision group, and gait speed for the primary was not significantly different from able-bodied at 2 years postoperation. Clinically, it would appear that rehabilitation strategies to improve gait endurance and gait speed could be implemented to further improve the gait of these patients.
We sought to determine the role of respiratory assessment by cardiorespiratory symptoms and/or oxygen saturation by pulse oximetry (SpO2) in predicting adverse maternal outcomes in women admitted to ...hospital with preeclampsia.
These data derive from an international, prospective multicentre cohort study, PIERS (Pre-eclampsia Integrated Estimate of RiSk), which assesses predictors of adverse outcomes in women admitted to tertiary perinatal units with preeclampsia. Univariate and multivariate analyses of cardiorespiratory symptoms and pulse oximetry were performed to assess their ability to predict a combined adverse maternal outcome developed through international Delphi consensus.
SpO2 successfully predicted adverse maternal outcomes; the area under the receiver-operator characteristic curve (AUC ROC) was 0.71 (95% CI 0.65 to 0.77). Combining the symptoms of chest pain and/or dyspnea with pulse oximetry improved this predictive ability (AUC ROC 0.73; 95% CI 0.67 to 0.78). When SpO2 was stratified into risk groups using inflection points on the ROC curve, the highest risk group (SpO2 90% to 93%) had an odds ratio of 18.1 (95% CI 8.2 to 40.2) for all outcomes within 48 hours when compared with the baseline group (SpO2 98% to 100%).
Assessing SpO2 aids in the assessment of maternal risk in women admitted to hospital with preeclampsia. An SpO2 value of ≤ 93% confers particular risk. The symptom complex of chest pain and/or dyspnea adds to the association.
Summary Background Although umbilical cord blood is an accepted alternative to bone marrow for transplantation, allele-matched bone marrow is generally regarded as the preferred graft source. Our aim ...was to assess leukaemia-free survival after transplantations of these alternatives compared with present HLA-matching practices, and to assess the relative effect of cell dose and HLA match, and their potential interaction on leukaemia-free survival after cord-blood transplantation. Methods Outcomes of 503 children (<16 years) with acute leukaemia and transplanted with umbilical cord blood were compared with outcomes of 282 bone-marrow recipients. All transplantation took place in the USA. Recipients of umbilical cord blood were transplanted with grafts that were HLA-matched (n=35) or HLA-mismatched for one (n=201) or two antigens (n=267) (typing at antigen level for HLA-A and HLA-B, and allele level for HLA-DRB1). Bone-marrow recipients were transplanted with grafts that were matched at the allele level for HLA-A, HLA-B, HLA-C, and HLA-DRB (n=116), or mismatched (n=166). The primary endpoint was 5-year leukaemia-free survival. Findings In comparison with allele-matched bone-marrow transplants, 5-year leukaemia-free survival was similar to that after transplants of umbilical cord blood mismatched for either one or two antigens and possibly higher after transplants of HLA-matched umbilical cord blood. Transplant-related mortality rates were higher after transplants of two-antigen HLA-mismatched umbilical cord blood (relative risk 2·31, p=0·0003) and possibly after one-antigen HLA-mismatched low-cell-dose umbilical-cord-blood transplants (1·88, p=0·0455). Relapse rates were lower after two-antigen HLA-mismatched umbilical-cord-blood transplants (0·54, p=0·0045). Interpretation These data support the use of HLA-matched and one- or two-antigen HLA-mismatched umbilical cord blood in children with acute leukaemia who need transplantation. Because better HLA matching and higher cell doses significantly decrease the risk of transplant-related mortality after umbilical-cord-blood transplantation, greater investment in large-scale banking is needed to increase HLA diversity.
Hip adductor spasticity and strength in participants with cerebral palsy (CP) were quantified before and after selective dorsal rhizotomy (SDR) and intensive physical therapy. Twenty-four ...participants with cerebral palsy (CP group) and 35 non-disabled participants (ND controls) were tested with a dynamometer (CP group: mean age 8 years 5 months, 13 males, 11 females; ND group: mean age 8 years 6 months, 19 males, 16 females). According to the Gross Motor Function Classification System (GMFCS), of the 24 participants with CP, eight were at level I, six were at level II, and 10 participants were at level III. For the spasticity measure, the dynamometer quantified the resistive torque of the hip adductors during passive abduction at 4 speeds. The adductor strength test recorded a maximum concentric contraction. CP group spasticity was significantly reduced following SDR and adductor strength was significantly increased after surgery. Both pre- and postoperative values remained significantly less than the ND controls. Spasticity results agreed with previous studies indicating a reduction. Strength results conflicted with previous literature subjectively reporting a decrease following SDR. However, results agreed with previous objective investigations examining knee and ankle strength, suggesting strength did not decrease following SDR.
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