Anupam Gupta

Effect of Partial Weight–Supported Treadmill Gait Training on Balance in Patients With Parkinson Disease

OBJECTIVE To investigate the role of conventional gait training and partial weight-supported treadmill gait training (PWSTT) in improving the balance of patients with Parkinson disease (PD). DESIGN Prospective randomized controlled design. SETTING National-level university tertiary hospital for mental health and neurosciences. PATIENTS Sixty patients with PD fulfilling the United Kingdom Brain Bank PD diagnostic criteria were recruited from the neurology outpatient department and movement disorder clinic. METHODOLOGY The patients were randomly assigned into 3 equal groups: (1) a control group that only received a stable dosage of dopaminomimetic drugs; (2) a conventional gait training (CGT) group that received a stable dosage of dopaminomimetic drugs and conventional gait training; and (3) a PWSTT group that received a stable dosage of dopaminomimetic drugs and PWSTT with unloading of 20% of body weight. The sessions for the CGT and PWSTT groups were provided for 30 minutes per day, 4 days per week, for 4 weeks (16 sessions). OUTCOME MEASURES The Unified Parkinson Disease Rating Scale (UPDRS) motor score, dynamic posturography, Berg Balance Scale, and Tinetti performance-oriented mobility assessment (POMA) were used as main outcome measures. RESULTS A significant interaction effect was observed in the UPDRS motor score, mediolateral index, Berg Balance Scale, limits of stability (LOS) total score, POMA gait score, and balance score. Post-hoc analysis showed that in comparison with the control group, the PWSTT group had a significantly better UPDRS motor score, balance indices, LOS in 8 directions, POMA gait, and balance score. The CGT group had a significantly better POMA gait score compared with control subjects. Compared with the CGT group, the PWSTT group had a significantly better UPDRS motor score, mediolateral index, POMA gait score, and LOS total score. CONCLUSION PWSTT may be a better interventional choice than CGT for gait and balance rehabilitation in patients with PD.

Surgical Management of Pressure Ulcers During Inpatient Neurologic Rehabilitation: Outcomes for Patients With Spinal Cord Disease

Abstract Background/Objective: To study efficacy of surgery in the management of pressure ulcers and evaluate the effect of simultaneous comprehensive rehabilitation in improving outcome. Method: Prospective, follow-up study. Setting: Neurologic rehabilitation unit of a tertiary care center. Participants: Patients with spinal cord diseases who had stage lll/IV pressure ulcers underwent surgical reconstruction and inpatient rehabilitation in 2005 with a minimum follow-up duration of 1year. Outcome Measures: Ulcer healing rate, postoperative complications, ulcers recurrence rate, and neurologic (ASIA grade), and functional recovery (Barthel Index). Statistical Analysis: Frequency analysis and paired t test on SPSS 13.0. Results: Surgical intervention was carried out in 25 participants (19 men, 6 women), having a total of 39 ulcers (13 Stage III, 23 Stage IV, 3 unstaged). Surgeries performed were debridement (3), split skin grafting (13), and flap mobilization and closure (23). Only 4 participants (16.6%) had initial complications: wound dehiscence (2) and delayed graft healing (2). Follow-up rate was 92.0% (23/25 patients), with a duration of 12 to 21 months (mean, 15.4 ± 7.45 months), and only 4 participants (17.3%) had ulcer recurrence. The majority of participants (13 of 25; 56.5%) improved neurologically on ASIA grade and functional evaluation on Barthel Index, suggesting statistically significant improvement (P < 0.005). Conclusions: All outcome variables showed significant improvement at follow-up with good ulcer healing rate (87.0%), low initial complication (16.6%) and recurrence rates (17.3%), and good neurologic (56.5%) and functional (P < 0.005) recovery. Timely surgical interventions are necessary for Stage III to IV pressure ulcers, and simultaneous inpatient rehabilitation significantly improves outcome of patients with spinal cord disease.

International Retrospective Comparison of Inpatient Rehabilitation for Patients With Spinal Cord Dysfunction Epidemiology and Clinical Outcomes

OBJECTIVE To describe and compare epidemiologic characteristics of patients with spinal cord dysfunction admitted to spinal rehabilitation units (SRUs) in 9 countries (Australia, Canada, Italy, India, Ireland, The Netherlands, Switzerland, United Kingdom, and United States). DESIGN Retrospective multicenter open-cohort case series. SETTING SRUs. PARTICIPANTS Patients (N=956) with initial onset of spinal cord dysfunction consecutively admitted between January 1, 2008, and December 31, 2010. Median age on admission was 59 years (interquartile range [IQR], 46-70), and 60.8% of patients were men. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Demographic characteristics (eg, age, sex), time frame over which clinical symptoms of spinal cord dysfunction developed, etiology, length of stay in hospital, level of lesion and American Spinal Injury Association Impairment Scale (AIS) grade, discharge destination, and inpatient mortality. RESULTS The time frame of onset of spinal cord dysfunction symptoms was as follows: ≤1 day (28.5%); ≤1 week (13.8%); >1 week but ≤1 month (10.5%), and >1 month (47.2%). Most common etiologies were degenerative conditions (30.8%), malignant tumors (16.2%), ischemia (10.9%), benign tumors (8.7%), and bacterial infections (7.1%). Most patients (72.3%) had paraplegia. The AIS grade on SRU admission was grade A in 14%, grade B in 6.5%, grade C in 24%, grade D in 52.4%, grade E in 0.2%, and missing in 2.9%. AIS grade significantly improved by discharge (z=-10.1, P<.0001). Median length of stay in the SRU was 46.5 days (IQR, 17-89.5). Most (80.5%) patients were discharged home. Differences between countries were found for most variables. CONCLUSIONS This international study of spinal cord dysfunction showed substantial variation of etiology, demographic, and clinical characteristics across countries. Further research, including multiple centers per country, are needed to separate country effects from center effects.

Urodynamics post stroke in patients with urinary incontinence: Is there correlation between bladder type and site of lesion?

Objective: Assessment of bladder by urodynamic study (UDS) in patients with urinary incontinence following stroke, and correlation with site of lesion. Study Design and Setting: Retrospective cross-sectional study in the neurological rehabilitation unit of a tertiary care institute. Materials and Methods: Forty patients (22 males) with arterial or venous, ischemic or hemorrhagic stroke, with urinary incontinence in the acute phase following the event, underwent UDS. Seventeen patients had right hemiplegia, 18 had left hemiplegia, and five had posterior circulation stroke with brainstem/cerebellar features. Bladder type was correlated with age, side, and site of lesion. Results: The mean age was 46.80 ± 16.65 years (range: 18-80 years). Thirty-six patients had arterial stroke and four had cortical venous thrombosis. UDS was performed after a mean of 28.32 ± 10.27 days (range: 8-53 days) after the stroke. All but one patient had neurogenic bladder dysfunction, with 36 patients (90%) having overactive detrusor (OD) and three having underactive/areflexic detrusor. Among the 36 patients with OD, 25 patients (62.5%) had OD without detrusor-sphincter dyssynergy (DSD) and 11 (27.5%) had OD with DSD. Bladder management was advised based on the UDS findings. No significant correlation (P > 0.05) was found between type of bladder and age or side and site of lesion. Conclusions: UDS is a useful tool to assess and manage the bladder following stroke with urinary incontinence. In this study, no significant correlation was found between UDS findings and site of lesion.

International Retrospective Comparison of Inpatient Rehabilitation for Patients With Spinal Cord Dysfunction: Differences According to Etiology

OBJECTIVES To describe and compare epidemiologic characteristics and clinical outcomes of patients with nontraumatic spinal cord dysfunction according to etiology. DESIGN Retrospective, multicenter open-cohort case series. SETTING Spinal rehabilitation units (SRUs) in 9 countries. PARTICIPANTS Patients (N=956; men, 60.8%; median age, 59.0y [interquartile range, 46-70.0y]; paraplegia, n=691 [72.3%]) with initial onset of spinal cord dysfunction consecutively admitted between January 1, 2008, and December 31, 2010. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Etiology of spinal cord dysfunction, demographic characteristics, length of stay (LOS) in rehabilitation, pattern of spinal cord dysfunction onset, discharge destination, level of spinal cord damage, and the American Spinal Injury Association Impairment Scale (AIS) grade on admission and discharge. RESULTS The most common etiologies were degenerative (30.8%), malignant tumors (16.2%), infections (12.8%), ischemia (10.9%), benign tumors (8.7%), other vascular (8.5%), and other conditions (12.1%). There were major differences in epidemiologic characteristics and clinical outcomes of patients with different etiologies of spinal cord dysfunction. Paraplegia was more common in patients with a malignant tumor and vascular etiologies, while tetraplegia was more common in those with a degenerative etiology, a benign tumor, and infections. Patients with a malignant tumor tended to have the shortest LOS in the SRU, while those with a vascular etiology tended to have the longest. Except for patients with a malignant tumor, all patient groups had a significant change in their AIS grade between admission and discharge. CONCLUSIONS This international study of spinal cord dysfunction showed substantial variation between the different etiologies regarding demographic and clinical characteristics, including changes in AIS between admission and discharge.

“Effect of pranayama and meditation as an add-on therapy in rehabilitation of patients with Guillain-Barré syndrome—a randomized control pilot study”

Objective: To study the add-on effects of pranayama and meditation in rehabilitation of patients with Guillain-Barré syndrome (GBS). Patients and Method: This randomized control pilot study was conducted in neurological rehabilitation unit of university tertiary research hospital. Twenty-two GBS patients, who consented for the study and satisfied selection criteria, were randomly assigned to yoga and control groups. Ten patients in each group completed the study. The yoga group received 15 sessions in total over a period of 3 weeks (1 h/session), one session per day on 5 days per week that consisted of relaxation, Pranayama (breathing practices) and Guided meditation in addition to conventional rehabilitation therapeutics. The control group received usual rehabilitation care. All the patients were assessed using Pittsburgh Sleep Quality Index, Numeric pain rating scale, Hospital anxiety and Depression scale and Barthel index score. Mann–Whitney U test and Wilcoxon’s signed rank test were used for statistical analysis. Results: Quality of sleep improved significantly with reduction of PSQI score in the yoga group (p = 0.04). There was reduction of pain scores, anxiety and depression in both the groups without statistical significance between groups (pain p > 0.05, anxiety p > 0.05 and depression p > 0.05). Overall functional status improved in both groups without significant difference (p > 0.05). Conclusions: Significant improvement was observed in quality of sleep with yogic relaxation, pranayama, and meditation in GBS patients. Implications for Rehabilitation GBS is an inflammatory demyelinating polyneuro radiculopathy with multiple complications requiring long term care. Yoga and other rehabilitation measures contribute in improving functional abilities, pain and sleep quality in GBS patients. This randomized control trial showed that short term yoga practice can improve the quality of sleep as compare to other rehabilitation measures in GBS patients

Quality of life and psychological problems in patients undergoing neurological rehabilitation.

Aim: To assess the quality of life (QoL) and prevalence of psychological problems (PP) in patients with neurological illness, and their correlation with functional abilities. Materials and Methods: Prospective cross-sectional study conducted in the neurological rehabilitation unit of tertiary research hospital in 30 consecutive hospitalized patients (21 men), age 16-55 years (34.63±11.87). Outcome Measure: WHOQoL-BREF was used to assess QoL. The prevalence of PP was recorded using Hospital Anxiety Depression Scale (HADS) and General Health Questionnaire (GHQ-12). QoL and HADS scores were correlated with functional abilities using mean Barthel Index (BI) Score. Results: The duration of illness was three to 30 months (10.63±7.83) and their primary diagnoses were stroke 12, traumatic spinal cord injury seven and non-traumatic spinal cord lesion 11. Twenty-two patients qualified for GHQ-12 caseness, with 15 patients having distress (score ≥15) and seven having severe problem and psychological distress (score≥20). Twenty five patients had abnormal anxiety and 17 had abnormal depression on HADS (abnormal = 8-21), with moderate to severe anxiety and depression (scores≥11) in nine and three patients respectively. The mean WHOQoL-BREF transformed scores (on WHOQoL 0-100 scale) were (38.83±8.02), (50.76±9.79), (48.53±18.46) and (49.13±10.63) in physical, psychological, social, and environmental domains respectively. The social domain of QoL had significant correlation (P<.05) with functional abilities. Conclusion: Patients with neurological disorders requiring inpatient rehabilitation have impaired QoL that affects all domains of life. There is high prevalence of psychological problems, including anxiety and depression. The social domain of QoL adversely affected functional abilities, but the correlation between PP and functional abilities was insignificant.

Partial Body Weight-Supported Treadmill Training in Patients With Parkinson Disease: Impact on Gait and Clinical Manifestation

OBJECTIVE To evaluate the effect of conventional gait training (CGT) and partial weight-supported treadmill training (PWSTT) on gait and clinical manifestation. DESIGN Prospective experimental research design. SETTING Hospital. PARTICIPANTS Patients with idiopathic Parkinson disease (PD) (N=60; mean age, 58.15±8.7y) on stable dosage of dopaminomimetic drugs were randomly assigned into the 3 following groups (20 patients in each group): (1) nonexercising PD group, (2) CGT group, and (3) PWSTT group. INTERVENTIONS The interventions included in the study were CGT and PWSTT. The sessions of the CGT and PWSTT groups were given in patients self-reported best on status after regular medications. The interventions were given for 30min/d, 4d/wk, for 4 weeks (16 sessions). MAIN OUTCOME MEASURES Clinical severity was measured by the Unified Parkinson Disease Rating Scale (UPDRS) and its subscores. Gait was measured by 2 minutes of treadmill walking and the 10-m walk test. Outcome measures were evaluated in their best on status at baseline and after the second and fourth weeks. RESULTS Four weeks of CGT and PWSTT gait training showed significant improvements of UPDRS scores, its subscores, and gait performance measures. Moreover, the effects of PWSTT were significantly better than CGT on most measures. CONCLUSIONS PWSTT is a promising intervention tool to improve the clinical and gait outcome measures in patients with PD.

Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit

Background: To assess the effect of single-stage multilevel soft-tissue surgery (Single Event Multiple Level Resections, SEMLR) on deformities and locomotion in patients with cerebral palsy (CP) with static contracture(s) in lower limbs. Patients and Methods: Study included 34 patients (M:F, 23:11) with mean age of 9.53 ± 3.92 years (4–16 years). Among them 22 had diplegia and four each had quadriplegia and right and left hemiplegia. Fourteen patients (41.2%) had their intelligence quotient (IQ) in the normal range (IQ ≥ 80), while others had mental retardation (MR) of varying severity: borderline MR (IQ = 70–79) in 12, mild MR (IQ = 50–69) in 5, and moderate MR (IQ = 35–49) in patients 3. All patients underwent surgery (total number of procedures 153, average 4.5 procedures/patient) over a period of 30 months (April 2005 to September 2007). Improvement in functional abilities and locomotion was assessed using Gross Motor Functional Classification Scale (GMFCS) scores and by physical examination. Results: Significant improvement in function was observed (P = 0.000) after surgery when comparing the preoperative and postoperative GMFCS scores. All patients were maintaining ambulation at a mean follow-up duration of 13.12 ± 6.07 months (3–24 months), with five patients using knee-ankle-foot orthoses (KAFO), 22 using ankle-foot orthoses (AFO), and six patients using knee gaiters. Sixteen patients were using walker, and two were using crutches as assistive devices. Conclusion: This study suggests that CP patients with good trunk control and static contractures at multiple joints in the lower limbs can be made ambulant with single-stage multilevel soft-tissue surgery. It has to be a team effort of the surgeon and the rehabilitation team in the postoperative period for the attainment of satisfactory goal.

Stroke with supernumerary phantom limb: case study, review of literature and pathogenesis.

Objective: Constitute hypothesis for origin of supernumerary phantom limb (SPL) after stroke. Method: Single case description, review of literature and formulation of hypothesis. Results: A 59-year-old lady was evaluated for complaints of left-sided hemiparesis and extra limbs attached to her left shoulder for the past 7 months. Neuropsychological assessment revealed left hemineglect with SPL, and profile suggested bilateral frontal, right parietotemporal and basal ganglia involvement. Magnetic resonance imaging brain scan showed gliotic cavity secondary to the old haematoma in right putamen with white matter changes in the right frontoparietotemporal lobes. Conclusions: The conceptual framework of body schema can be used to classify many of the neurological disorders of body representation. Generation of SPL comes under the subtype of pathology of updating among the disorders of body schema. The continuous updating allows the body schema to modulate perceptual processing of objects according to their position in space. Brain areas classified as parts of motor system can, under pathological conditions (haemorrhage), influence body perception. So, when she used to move her arm, the representation of the estimated position was not updated by the motor commands. Sensory and motor information therefore becomes discrepant, and failure to integrate these two sources of information leads to loss of normal coherence, and the perceived shape of the body was altered by adding a SPL to accommodate the discrepancy.