Gerard M. Ribbers

Motor Recovery and Cortical Reorganization After Mirror Therapy in Chronic Stroke Patients A Phase II Randomized Controlled Trial

Objective. To evaluate for any clinical effects of home-based mirror therapy and subsequent cortical reorganization in patients with chronic stroke with moderate upper extremity paresis. Methods. A total of 40 chronic stroke patients (mean time post .onset, 3.9 years) were randomly assigned to the mirror group (n = 20) or the control group (n = 20) and then joined a 6-week training program. Both groups trained once a week under supervision of a physiotherapist at the rehabilitation center and practiced at home 1 hour daily, 5 times a week. The primary outcome measure was the Fugl-Meyer motor assessment (FMA). The grip force, spasticity, pain, dexterity, hand-use in daily life, and quality of life at baseline—posttreatment and at 6 months—were all measured by a blinded assessor. Changes in neural activation patterns were assessed with functional magnetic resonance imaging (fMRI) at baseline and posttreatment in an available subgroup (mirror, 12; control, 9). Results. Posttreatment, the FMA improved more in the mirror than in the control group (3.6 ± 1.5, P < .05), but this improvement did not persist at follow-up. No changes were found on the other outcome measures (all Ps >.05). fMRI results showed a shift in activation balance within the primary motor cortex toward the affected hemisphere in the mirror group only (weighted laterality index difference 0.40 ± 0.39, P < .05). Conclusion. This phase II trial showed some effectiveness for mirror therapy in chronic stroke patients and is the first to associate mirror therapy with cortical reorganization. Future research has to determine the optimum practice intensity and duration for improvements to persist and generalize to other functional domains.

Energy expenditure in chronic stroke patients playing Wii Sports: A pilot study

BackgroundStroke is one of the leading causes of long-term disability in modern western countries. Stroke survivors often have functional limitations which might lead to a vicious circle of reduced physical activity, deconditioning and further physical deterioration. Current evidence suggests that routine moderate- or vigorous-intensity physical activity is essential for maintenance and improvement of health among stroke survivors. Nevertheless, long-term participation in physical activities is low among people with disabilities. Active video games, such as Nintendo Wii Sports, might maintain interest and improve long-term participation in physical activities; however, the intensity of physical activity among chronic stroke patients while playing Wii Sports is unknown. We investigated the energy expenditure of chronic stroke patients while playing Wii Sports tennis and boxing.MethodsTen chronic (≥ 6 months) stroke patients comprising a convenience sample, who were able to walk independently on level ground, were recruited from a rehabilitation centre. They were instructed to play Wii Sports tennis and boxing in random order for 15 minutes each, with a 10-minute break between games. A portable gas analyzer was used to measure oxygen uptake (VO2) during sitting and during Wii Sports game play. Energy expenditure was expressed in metabolic equivalents (METs), calculated as VO2 during Wii Sports divided by VO2 during sitting. We classified physical activity as moderate (3-6 METs) or vigorous (> 6 METs) according to the American College of Sports Medicine and the American Heart Association Guidelines.ResultsAmong the 10 chronic stroke patients, 3 were unable to play tennis because they had problems with timing of hitting the ball, and 2 were excluded from the boxing group because of a technical problem with the portable gas analyzer. The mean (± SD) energy expenditure during Wii Sports game play was 3.7 (± 0.6) METs for tennis and 4.1 (± 0.7) METs for boxing. All 8 participants who played boxing and 6 of the 7 who played tennis attained energy expenditures > 3 METs.ConclusionsWith the exception of one patient in the tennis group, chronic stroke patients played Wii Sports tennis and boxing at moderate-intensity, sufficient for maintaining and improving health in this population.

Coping strategies as determinants of quality of life in stroke patients: a longitudinal study

Background: Quality of life (QoL) is reduced for stroke patients and coping strategies have been suggested as determinants of QoL. Thus far the relationship between coping and QoL has only been examined in small-scale cross-sectional designs. Therefore, the current study set out to examine this relationship in a longitudinal setting. Methods: Stroke patients who were discharged home were interviewed at 4 different time points; just before discharge (T1), and 2 months (T2), 5 months (T3) and 9–12 months after discharge (T4). QoL was measured by the EQ-5D index score and the SF-36 utility score and coping expressed in terms of tenacious goal pursuit and flexible goal adjustment. Modified Rankin scale was assessed as a measure of general functioning. Results: Eighty stroke patients were included. Coping was not predictive of QoL at T1 and T2 but rather at T3 and T4. At T4 both coping strategies determined the levels of QoL as measured with the EQ-5D index score; higher levels of tenacious goal pursuit as well as flexible goal adjustment were associated with higher levels of QoL. This regression model explained 44% of the variance. Conclusions: Coping is a powerful determinant of QoL, but only more than 5 months after discharge; before this time QoL is mainly determined by general functioning. Both coping strategies were important determinants of QoL.

Traumatic brain injury: classification of initial severity and determination of functional outcome

Purpose : The aim of the present manuscript is to review current methods for classifying initial severity and final outcome in traumatic brain injury (TBI) and to suggest a direction and form of further research. Method : The literature on valid and reliable measurements used in TBI-research for classifying initial severity and final outcome was reviewed. Results : Classifying initial severity in patients with head injury according to clinical condition or CT-parameters is valid. Classifying outcome according to measurement tools of disability showed adequate validity and reliability. Conclusions : Future research in TBI outcome, particularly in rehabilitation medicine, should focus on determinants of outcome, identifying those patients who will have the greatest chance of benefiting from intensive rehabilitation programmes. More research is needed to determine the long-term functional outcome in TBI, the long-term socio-economic costs, and the influence of behavioural problems on family cohesion. Finally, validation of outcome measures is required in the TBI-population; the relative value of various outcome measures needs to be determined, and the usefulness and applicability of measures for health related quality of life in TBI should be established.

The neuronal correlates of mirror therapy: an fMRI study on mirror induced visual illusions in patients with stroke

Aim To investigate the neuronal basis for the effects of mirror therapy in patients with stroke. Methods 22 patients with stroke participated in this study. The authors used functional MRI to investigate neuronal activation patterns in two experiments. In the unimanual experiment, patients moved their unaffected hand, either while observing it directly (no-mirror condition) or while observing its mirror reflection (mirror condition). In the bimanual experiment, patients moved both hands, either while observing the affected hand directly (no-mirror condition) or while observing the mirror reflection of the unaffected hand in place of the affected hand (mirror condition). A two-factorial analysis with movement (activity vs rest) and mirror (mirror vs no mirror) as main factors was performed to assess neuronal activity resultant of the mirror illusion. Results Data on 18 participants were suitable for analysis. Results showed a significant interaction effect of movement×mirror during the bimanual experiment. Activated regions were the precuneus and the posterior cingulate cortex (p<0.05 false discovery rate). Conclusion In this first study on the neuronal correlates of the mirror illusion in patients with stroke, the authors showed that during bimanual movement, the mirror illusion increases activity in the precuneus and the posterior cingulate cortex, areas associated with awareness of the self and spatial attention. By increasing awareness of the affected limb, the mirror illusion might reduce learnt non-use. The fact that the authors did not observe mirror-related activity in areas of the motor or mirror neuron system questions popular theories that attribute the clinical effects of mirror therapy to these systems.

A Prospective Study on Employment Outcome 3 Years After Moderate to Severe Traumatic Brain Injury

OBJECTIVES To evaluate the employment outcome in patients with moderate to severe traumatic brain injury (TBI) and to identify which patients are at risk of unemployment 3 years after injury. DESIGN Prospective cohort study. SETTING Patients with moderate and severe TBI discharged from the neurosurgery departments of 3 level 1 trauma centers in The Netherlands. PARTICIPANTS Patients aged 18 to 65 years (N=113; mean age ± SD, 33.2±13.1y; 73% men) who were hospitalized with moderate (26% of patients) to severe (74% of patients) TBI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The main outcome measure was employment status. Potential predictors included patient characteristics, injury severity factors, functional outcome measured at discharge from the acute hospital with the Glasgow Outcome Scale (GOS), Barthel Index (BI), and FIM, and cognitive functioning measured with the Functional Assessment Measure (FAM). RESULTS Ninety-four patients (83%) completed the 3-year follow-up. The employment rate dropped from 80% preinjury to 15% at 3 months postinjury and gradually increased to 55% after 3 years. The employment rate significantly increased from 3 months up to 1 year, but it did not change significantly from 1 to 3 years postinjury. Age, length of hospital stay, discharge to a nursing home (vs home), psychiatric symptoms, and BI, GOS, FIM, and FAM scores were found to be significant univariate determinants for employment status. By using multiple logistic regression analysis, the FAM score (adjusted odds ratio 1.1; P<.000) and psychiatric symptoms (adjusted odds ratio .08; P<.019) were selected as independent predictors for employment status. A FAM cutoff score of less than 65 to identify patients at risk of long-term unemployment had a good diagnostic value. CONCLUSIONS Patients with TBI with psychiatric symptoms and impaired cognitive functioning at hospital discharge are at the highest risk of long-term unemployment. These factors should be the focus of vocational rehabilitation.

PROGNOSIS OF SIX-MONTH FUNCTIONING AFTER MODERATE TO SEVERE TRAUMATIC BRAIN INJURY: A SYSTEMATIC REVIEW OF PROSPECTIVE COHORT STUDIES

OBJECTIVE To systematically review which determinants, assessed within the first month after a moderate to severe traumatic brain injury, predict 6-month functional outcome. METHODS Databases were searched for relevant publications between 1995 and August 2008. Selection criteria were: prospective cohort studies; determinants associated with functional outcome 6 months after moderate to severe traumatic brain injury in adult patients; determinants assessed within the first month post-injury. Two reviewers independently performed the selection and quality assessment. A best- evidence synthesis was performed for prognostic factors assessed in 2 or more studies. RESULTS Twenty-eight studies were included, 27 of which were high quality. Most studies used the Glasgow Outcome Score at 6 months post-injury as outcome measure, sometimes in combination with other outcome measures. Strong evidence for predicting outcome at 6 months was found for the Glasgow Coma Scale (GCS), GCS admission, motor score, midline shift on computed tomography scan, subdural haematoma and pulsatility index. Strong evidence of no association was found for gender and intraventricular haemorrhage. For other determinants, inconclusive or no evidence was found. CONCLUSION GCS, GCS on admission, motor score, midline shift, subdural haematoma and pulsatility index predicted outcome 6 months after traumatic brain injury. Gender and intraventricular haemorrhage did not have predictive value.

Quantifying Nonuse in Chronic Stroke Patients: A Study Into Paretic, Nonparetic, and Bimanual Upper-Limb Use in Daily Life

OBJECTIVE To quantify uni- and bimanual upper-limb use in patients with chronic stroke in daily life compared with healthy controls. DESIGN Cross-sectional observational study. SETTING Outpatient rehabilitation center. PARTICIPANTS Patients with chronic stroke (n=38) and healthy controls (n=18). INTERVENTION Not applicable. MAIN OUTCOME MEASURES Upper-limb use in daily life was measured with an accelerometry-based upper-limb activity monitor, an accelerometer based measurement device. Unimanual use of the paretic and the nonparetic side and bimanual upper-limb use were measured for a period of 24 hours. Outcomes were expressed in terms of both duration and intensity. RESULTS Patients used their unaffected limb much more than their affected limb (5.3h vs 2.4h), while controls used both limbs a more equal amount of time (5.4h vs 5.1h). Patients used their paretic side less than controls used their nondominant side and their nonparetic side more than controls their dominant side. The intensity with which patients used their paretic side was lower than that with which controls used their nondominant side, while that of the nonparetic side was higher than that of the dominant side of controls. Finally, patients used their paretic side almost exclusively in bimanual activities. During bimanual activities, the intensity with which they used their affected side was much lower than that of the nonaffected side. CONCLUSION Our data show considerable nonuse of the paretic side, both in duration and in intensity, and both during unimanual and bimanual activities in patients with chronic stroke. Patients do compensate for this with increased use of the nonparetic side.

COMMUNITY INTEGRATION FOLLOWING MODERATE TO SEVERE TRAUMATIC BRAIN INJURY: A LONGITUDINAL INVESTIGATION

OBJECTIVE To evaluate the course and identify determinants of community integration for up to 3 years following moderate to severe traumatic brain injury. DESIGN Prospective cohort study. PATIENTS A total of 119 moderate to severe traumatic brain injury patients aged 16-67 years. METHODS The Community Integration Questionnaire was completed at 3, 6, 12, 18, 24 and 36 months post-injury. Repeated measures analysis of variance was performed to determine changes over time in the Community Integration Questionnaire and its subscales. Bivariate and multivariate regression analyses were used to identify determinants of community integration 36 months post-injury. RESULTS Compared with pre-injury, mean home integration, social integration, productivity, and total questionnaire scores decreased 3 months post-injury. Patient scores showed maximal improvement during the first year post--injury. Mean home integration, productivity, and total scores increased to a lesser extent during years 1-3 post-injury. Age, Barthel Index scores, hospital discharge destination, and pre-injury community integration scores were the major determinants of community integration 36 months post-injury (R2 = 60%). CONCLUSION After an initial decline, mean community integration scores gradually improve following moderate to severe traumatic brain injury. Understanding the course and determinants of community integration is necessary in order to determine functional prognosis following traumatic brain injury.

Reflex sympathetic dystrophy: Is the immune system involved?

OBJECTIVE Evaluation of immune system function in patients with reflex sympathetic dystrophy (RSD). DESIGN Survey on blood samples obtained from RSD patients and from a randomly selected control group. The lymphocyte populations (T, B, NK cells), and the activated T cells (CD25, and HLA-Dr-positive CD4 and CD8 cells) were analyzed by flow cytometry with dual-color direct immunofluorescence after whole-blood lysis. Clinical chemistry parameters were analyzed in additional serum samples. SETTING Tertiary care center (outpatient rehabilitation clinic). SUBJECTS Thirteen patients (nine women) with RSD and a control group of 21 healthy individuals. MAIN OUTCOME MEASURES The results of the flow cytometry analysis of RSD patients were related to those of the control subjects. Means were analyzed, and confidence intervals for differences of the means were calculated. The means of the clinical chemical analysis were related to local reference values. RESULTS The flow cytometry analysis did not differ between RSD patients and healthy controls. Although in some patients an individual parameter of clinical chemical analysis differed from its reference value, all of the mean values were within reference limits. Stratification on medications with immunomodulatory effects and on probability of a definite diagnosis of RSD had no influence on the results. CONCLUSION No association between immunologic indices and RSD was found. This finding is relevant, because recent theories stress that it is not the sympathetic nervous system but a local inflammatory reaction that is fundamental in the pathogenesis of RSD. The results of this study do not support this theory.