A.J.H. Prevo

Probability of Regaining Dexterity in the Flaccid Upper Limb Impact of Severity of Paresis and Time Since Onset in Acute Stroke

BACKGROUND AND PURPOSE To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm, the effects of change in motor function over time on the accuracy of prediction were evaluated, and a prediction model for the probability of regaining dexterity at 6 months was developed. METHODS In 102 stroke patients, dexterity and paresis were measured with the Action Research Arm Test, Motricity Index, and Fugl-Meyer motor evaluation. For model development, 23 candidate determinants were selected. Logistic regression analysis was used for prognostic factors and model development. RESULTS At 6 months, some dexterity in the paretic arm was found in 38%, and complete functional recovery was seen in 11.6% of the patients. Total anterior circulation infarcts, right hemisphere strokes, homonymous hemianopia, visual gaze deficit, visual inattention, and paresis were statistically significant related to a poor arm function. Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity (Action Research Arm Test >or=10 points) from 74% (positive predictive value [PPV], 0.74; 95% confidence interval [CI], 0.63 to 0.86) to 94% (PPV, 0.83; 95% CI, 0.76 to 0.91) at 6 months. No change in probabilities of prediction dexterity was found after 4 weeks. CONCLUSIONS Based on the Fugl-Meyer scores of the flaccid arm, optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset. Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months.

High prevalence of incontinence among young adults with spina bifida: description, prediction and problem perception

Study design:Cross-sectional study.Objectives:To study the prevalence of incontinence, problem perception and determinants of urinary and faecal incontinence in young adults with spina bifida.Setting:Nation-wide study in the Netherlands.Participants:A total of 179 of 350 invited patients participated, including 37 patients with spina bifida occulta and 142 with spina bifida aperta, of whom 119 had hydrocephalus; 41% were male and mean age was 20.4 (range 16–25 years).Methods:Data were collected from interviews, physical examination, neuropsychological tests and medical records.Results:Urinary and faecal incontinence was common in young adults with spina bifida (60.9 and 34.1%, respectively), regardless of the bladder and bowel management they used. The majority of urinary and faecal incontinent patients perceived this as a problem (69.7 and 77.0%, respectively). Spina bifida aperta, hydrocephalus and a level of lesion of L5 or above were associated with patients suffering from urinary and/or faecal incontinence. Predictors of perceiving urinary incontinence as a problem were, in addition to being incontinent, not having hydrocephalus and having a level of lesion of L5 or above. The only predictor of perceiving faecal incontinence as a problem was the frequency of incontinence.Conclusion:A majority of young adults with spina bifida suffer from urinary and faecal incontinence and most of them perceive their incontinence as a problem. Therefore, further efforts are important to improve urinary and faecal continence.

Secondary impairments in young adults with spina bifida

The aim of this study was to examine the prevalence of secondary impairments in young adults with spina bifida and to relate the prevalence to the type of spina bifida and the level of lesion. This cross‐sectional study is part of the ASPINE (Adolescents with Spina Bifida in the Netherlands) study. Data were collected on medical history, hydrocephalus (shunt: yes/no), neurological level of lesion (International Standards for Neurological and Functional Classification of Spinal Cord Injury), visual acuity (Landolt rings), spasticity (Modified Ash worth Scale), contractures (range of motion), scoliosis (deviation from perpendicular), ambulation (Hoffer criteria), pressure sores and blood pressure (physical examination), epilepsy, pain, incontinence and sexuality (questionnaire), and cognitive functioning (Raven Standard Progressive Matrices). In total, 179 patients with spina bifida participated (41% male, age range 16 to 25 years, mean 20 years 9 months, SD 2 years 11 months). These were 37 patients with spina bifida occulta, 119 patients with spina bifida aperta and hydrocephalus (AHC+) and 23 patients with spina bifida aperta without hydrocephalus (AHC−). Of our patient group, 73 had a high‐level lesion (L2 and above), 68 a mid‐level lesion (L3 to L5), and 38 a low‐level lesion (S1 and below). Both subdivisions were strongly related with patients with higher lesions more often having hydrocephalus. Most secondary impairments were found for patients with AHC+, and patients with AHC− were mostly comparable to patients with spina bifida occulta. According to level of lesion, most medical problems were found in the high‐level lesion group. However, all subgroups suffered from health problems.

Predicting long-term independency in activities of daily living after middle cerebral artery stroke : Does information from MRI have added predictive value compared with clinical information?

Background and Purpose— To investigate whether neuroimaging information has added predictive value compared with clinical information for independency in activities of daily living (ADL) 1 year after stroke. Methods— Seventy-five first-ever middle cerebral artery stroke survivors were evaluated in logistic regression analyses. Model 1 was derived on the basis of clinical variables; for model 2, neuroimaging variables were added to model 1. Independent variables were stroke severity (National Institutes of Health Stroke Scale), consciousness (Glasgow Coma Scale), urinary continence, demographic variables (age, gender, relationship, educational level), hospital of admission, and clinical instruments: sitting balance (trunk control test), motor functioning (Motricity Index), and ADL (Barthel Index). Neuroimaging variables, determined on conventional MRI scans, included: number of days to scanning, lesion volume, lesion localization (cortex/subcortex), hemisphere, and the presence of white matter lesions. ADL independency was defined as 19 and 20 points on Barthel Index. Differences in accuracy of prediction of ADL independence between models 1 and 2 were analyzed by comparing areas under the curve (AUC) in a receiver operating characteristic analysis. Results— Model 1 contained as significant predictors: age and ADL (AUC 0.84), correctly predicting 77%. In model 2, number of days to scanning, hemisphere, and lesion volume were added to model 1, increasing the AUC from 0.84 to 0.87, accurately predicting 83% of the surviving patients. Conclusions— Clinical variables in the second week after stroke are good predictors for independency in ADL 1 year after stroke. Neuroimaging variables on conventional MRI scans do not have added value in long-term prediction of ADL.

Cognitive status of young adults with spina bifida

The cognitive status of 168 Dutch young adults (103 females, 65 males; mean age 20 years 9 months, age range 16 to 25 years) with spina bifida (SB) was examined. The main purpose was to establish the effect of the type of SB (occulta or aperta) and the effect of hydrocephalus (HC) within the group with SB aperta (AHC+). Results indicated, on average, a lower cognitive status of persons with AHC+ (n=111) than of persons with SB occulta (n=37) and of persons with SB aperta without HC (AHC-; n=20). Almost half the young adults with AHC+ had cognitive impairments of some sort. These included more domain specific impairments (70%) as well as a more general cognitive deficit (30%). Cognitive status of persons with SB occulta and of those with AHC- was similar to that in the healthy population. The presence of associated pathology, rather than SB per se, has a negative effect on cognitive status.

Functional independence among young adults with spina bifida, in relation to hydrocephalus and level of lesion

Knowledge about the level of functional independence that can be expected in adulthood might support decisions on the treatment of newborn infants with spina bifida. This study determined functional independence among young adults with spina bifida and its relationships with pathological characteristics known from birth (hydrocephalus and level of lesion). Data were collected from medical records and by physical examination. Functional independence was assessed on six domains (self‐care, sphincter control, transfers, locomotion, communication, and social cognition) using the Functional Independence Measure (FIM). Participants were 165 patients with spina bifida (69 males, 96 females; age range 16 to 25y, mean 20y 9mo [SD 2.9]; 117 with hydrocephalus). Patients without hydrocephalus were independent for all FIM domains except sphincter control, as were patients with hydrocephalus with a lesion level below L2. Most patients with hydrocephalus and a lesion at L2 or above were dependent as regards sphincter control (98%), locomotion (79%), and self‐care (54%), and quite a few needed support in transfers (38%), social cognition (29%), and communication (15%).

Life satisfaction of young adults with spina bifida

This study concerns life satisfaction and its determinants in Dutch young adults with spina bifida (SB). Data on life satisfaction (Life Satisfaction Questionnaire [LiSat‐9]) were related to hydrocephalus, lesion level, disabilities, and demographic variables. In total, 179 young adults with SB participated (41% male, age range 16‐25y; 79% SB aperta, 67% hydrocephalus [HC], 39% wheelchair‐dependent). Most were satisfied with their life as a whole (24% dissatisfied). No difference was found from a population reference group (28% dissatisfied). Highest proportions of dissatisfaction were found for financial situation (44%), partnership relations (49%), and sex life (55%). Least dissatisfaction was found for contact with friends (17%) and families (15%). Young adults with SB and HC were more satisfied with their financial situation and family life but were less satisfied with self‐care ability and partnership relations than those without HC and the reference group. However, except for self‐care ability, relationships between life satisfaction and having SB were weak. In conclusion, self‐care ability and partnership relations were rated least favourable and may need more attention from care providers. Overall, SB does not seem to be an important determinant of life satisfaction.

Restrictions in social participation of young adults with spina bifida

Purpose. To determine participation restrictions of young adults with spina bifida (SB) in relation to health condition and activity limitations. Method. A total of 179 persons aged 16–25 years and born with SB participated in a cross-sectional study. The main outcome on four domains of participation (independent living, employment, education and partner relationships) was assessed using a structured questionnaire. Results. At the mean age of 21 years only 16% were living independently, more than one-third of the participants went to special secondary education, 53% of those who finished education did not have a regular job and 71% did not have a partner. Health condition variables (type of SB, hydrocephalus and level of lesion) and to a lesser extent activity limitations (wheelchair dependence and incontinence) were significant determinants for having participation restrictions. Perceived hindrances in participation included long-distance transportation (19–36%), accessibility (10–42%), physical impairments (22–40%), emotional barriers (20–32%) and financial limits (3–17%). More severe SB, defined as hydrocephalus, high level of lesion and wheelchair dependence, was related with more experienced hindrances due to long-distance transportation accessibility of buildings. Conclusions. Many young adults with spina bifida experience participation restrictions. Severity of SB was negatively related to participation. Social integration should be a major focus in the professional guidance of youngsters with physical disabilities.

Perceived health in young adults with spina bifida

The aims of this study were to compare the perceived health of young adults with spina bifida with a population without disability, and to determine the effect of the disease characteristics and resulting impairments on perceived health. This cross‐sectional study is part of the Adolescents with Spina Bifida in the Netherlands study. Data were collected by physical examination and a questionnaire. In total, 179 patients (age range 16‐25y) participated in the study and perceived health data were completed for 164 participants (92 females, 72 males; mean age 20y 7mo [SD 2y 9mo]). Twenty‐six participants had spina bifida occulta and 138 had spina bifida aperta, of whom 115 also had hydrocephalus. Perceived health was measured with the Medical Outcome Study 36‐item Short‐form Health Survey (SF‐36), a generic health status measure. SF‐36 scores of young adults with spina bifida were below those of an age‐matched population group for six of the eight domains. This difference was largest for the physical functioning domain. Although these differences were statistically significant they were small. Findings for the emotional health domains (vitality, mental health, role problems due to emotional problems) did not differ at all from the population group.

IS COGNITIVE FUNCTIONING ASSOCIATED WITH SUBJECTIVE QUALITY OF LIFE IN YOUNG ADULTS WITH SPINA BIFIDA AND HYDROCEPHALUS

OBJECTIVE To test the hypothesis that cognitive functioning is associated with subjective quality of life of young adults with spina bifida and hydrocephalus (SBHC). DESIGN Cross-sectional multi-centre study in The Netherlands. SUBJECTS A total of 110 young adults with SBHC (16-25 years old, 63% female). METHODS Cognitive domains measured were intelligence (Raven Standard Progressive Matrices), memory (Wechsler Memory Scale) and executive functioning (Wisconsin modified Card Sorting Test (WmCST), Trail Making Test A and B (TMT) and UNKA word production test). Subjective quality of life was measured with a visual analogue scale. Correlations and hierarchical regression analysis controlling for age, gender and functional independence were applied. RESULTS The TMT score was significantly associated (-0.25) with subjective quality of life. In the hierarchical regression analysis both the WmCST and TMT scores were significant determinants of subjective quality of life (Beta values 0.24 and -0.31 respectively). Intelligence, memory and word production were not related to subjective quality of life. All 5 cognitive variables together explained a significant additional 14.6% of the variance of subjective quality of life (total explained variance 19.9%). CONCLUSION Executive functioning was associated with subjective quality of life in young adults with spina bifida and hydrocephalus. This finding underlines the importance of examining cognitive functioning of persons with SBHC in addition to medical and functional status in medical care and outcome research.