J. Marsden

Clinical management of spasticity

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Deep abdominal muscle activity following supratentorial stroke

This study assessed the level and symmetry of deep abdominal muscle activation following a supratentorial stroke during a modified hip flexion task. Movement-related activation levels in the transversus abdominus (TrA) and internal oblique (IO) were investigated in people with a subacute (<3.25months) supratentorial stroke (n=11) and a matched control group (n=11). Electromyographic activity in TrA and IO were recorded using fine wires inserted under ultrasound guidance while participants performed a standardised head lift or unilateral hip flexion. During head lift there was no significant difference in the amplitude of activation ipsi- and contra-lateral to the stroke or between groups. During unilateral hip flexion the TrA and IO were activated more on both sides when moving the paretic leg. In the control group muscle activity was modulated by task with activity being higher ipsilateral to the moving leg; in contrast in the stroke group IO muscle activity tended to be higher on the non-paretic side irrespective of moving limb. Greater TrA and IO muscle activity during hip flexion of the paretic leg may represent compensatory activity that acts to facilitate activation of the paretic hip flexors and/or the presence of overflow.

Effectiveness of non-pharmacological interventions in treating orthostatic hypotension in the elderly and people with a neurological condition

REVIEW QUESTION/OBJECTIVEnThe objectives of the review are to determine:Specifically, the review question is:What is the evidence base for non-pharmacological interventions in treating orthostatic hypotension (OH) in elderly people and people with a neurological condition?

Service delivery for people with hereditary spastic paraparesis living in the South West of England

Abstract Purpose: Hereditary Spastic Paraplegia (HSP) is an inherited nervous system disorder characterized by development of leg weakness, spasms and stiffness. While generally acknowledged that health and social care services can minimise symptoms and improve quality of life, there is a lack of research exploring this from the perspective of people affected by HSP. This qualitative study explored the users and providers experience of using rural services. Method: Focus groups and interviews were undertaken of people with HSP (nu2009=u200914), carers (nu2009=u20096) and professionals (nu2009=u200912), to describe their experience of service provision and to suggest improvements for care. These were taped, transcribed and analysed. Results: Four themes emerged: (1) Diagnosis, symptoms and finding support; (2) Therapy, treatment and the delivery of care; (3) Managing the disease together; and (4) The way forward. Conclusions: Rehabilitation and support for self-management is valued by those affected with HSP throughout the disease trajectory from diagnosis onwards. Key to this is the development of a partnership approach which includes carers. Single point, well-informed, gatekeepers may enhance the coordination and delivery of care in rural areas. These findings underline current guidance promoting a holistic approach for people with neurological conditions. Implications for Rehabilitation People with HSP see as a high priority the need for additional neuro-physiotherapy services and emotional support services. Single point, well-informed, gatekeepers are essential to coordinate care, especially with rare diseases. Health professionals need more education and training about the disease process and its consequences for people affected by HSP, including the carer burden. People with HSP require better self-management advice, information and support.

Standing up in multiple sclerosis (SUMS): protocol for a multi-centre randomised controlled trial evaluating the clinical and cost effectiveness of a home-based self-management standing frame programme in people with progressive multiple sclerosis

BackgroundMultiple sclerosis (MS) is an incurable, unpredictable but typically progressive neurological condition. It is the most common cause of neurological disability in young adults. Within 15xa0years of diagnosis, approximately 50xa0% of affected people are unable to walk unaided, and over time an estimated 25xa0% depend on a wheelchair. Typically, people with such limited mobility are excluded from clinical trials. Severely impaired people with MS spend much of their day sitting, often with limited ability to change position. In response, secondary complications can occur including: muscle wasting, pain, reduced skin integrity, spasms, limb stiffness, constipation, and associated psychosocial problems such as depression and lowered self-esteem. Effective self-management strategies, which can be implemented relatively easily and cheaply within people’s homes, are needed to improve or maintain mobility and reduce sedentary behaviour. However this is challenging, particularly in the latter stages of disease. Regular supported standing using standing frames is one potential option.Methods/DesignSUMS is a pragmatic multi-centre randomised controlled trial evaluating use of Oswestry standing frames with blinded outcome assessment and full economic evaluation. Participants will be randomly allocated (1:1) to either a home-based, self-management standing programme (with advice and support) along with their usual care or to usual care alone. Those in the intervention group will be asked to stand for a minimum of 30xa0min three times weekly over 20xa0weeks. Each participant will be followed-up at 20 and 36xa0weeks post baseline. The primary clinical outcome is motor function, assessed using the Amended Motor Club Assessment. The primary economic endpoint is quality-adjusted life years. The secondary outcomes include measures of explanatory physical impairments, key clinical outcomes, and health–related quality of life. An embedded qualitative component will explore participant’s and carer’s experiences of the standing programme.DiscussionThis is the first large scale multi-centre trial to assess the clinical and cost effectiveness of a home based standing frame programme for people who are severely impaired by MS. If demonstrated to be effective and cost-effective, we will use this evidence to develop recommendations for a health service delivery model which could be implemented across the United Kingdom.Trial registrationISRCTN69614598Date of registration3.2.16 (retrospectively registered)

Balance Right in Multiple Sclerosis (BRiMS): a guided self-management programme to reduce falls and improve quality of life, balance and mobility in people with secondary progressive multiple sclerosis: a protocol for a feasibility randomised controlled trial

BackgroundImpaired mobility is a cardinal feature of multiple sclerosis (MS) and is rated by people with MS as their highest priority. By the secondary progressive phase, balance, mobility and physical activity levels are significantly compromised; an estimated 70% of people with secondary progressive MS fall regularly. Our ongoing research has systematically developed ‘Balance Right in MS’ (BRiMS), an innovative, manualised 13-week guided self-management programme tailored to the needs of people with MS, designed to improve safe mobility and minimise falls. Our eventual aim is to assess the clinical and cost effectiveness of BRiMS in people with secondary progressive MS by undertaking an appropriately statistically powered, multi-centre, assessor-blinded definitive, randomised controlled trial. This feasibility study will assess the acceptability of the intervention and test the achievability of running such a definitive trial.Methods/designThis is a pragmatic multi-centre feasibility randomised controlled trial with blinded outcome assessment. Sixty ambulant people with secondary progressive MS who self-report two or more falls in the previous 6xa0months will be randomly allocated (1:1) to either the BRiMS programme plus usual care or to usual care alone. All participants will be assessed at baseline and followed up at 15xa0weeks and 27xa0weeks post-randomisation.The outcomes of this feasibility trial include:Feasibility outcomes, including trial recruitment, retention and completionAssessment of the proposed outcome measures for the anticipated definitive trial (including measures of walking, quality of life, falls, balance and activity level)Measures of adherence to the BRiMS programmeData to inform the economic evaluation in a future trialProcess evaluation (assessment of treatment fidelity and qualitative evaluation of participant and treating therapist experience)DiscussionThe BRiMS intervention aims to address a key concern for MS service users and providers. However, there are several uncertainties which need to be addressed prior to progressing to a full-scale trial, including acceptability of the BRiMS intervention and practicality of the trial procedures. This feasibility trial will provide important insights to resolve these uncertainties and will enable a protocol to be finalised for use in the definitive trial.Trial registrationISRCTN13587999.

What is the longitudinal profile of impairments and can we predict difficulty caring for the profoundly-affected arm in the first year post-stroke?

OBJECTIVESnTo establish the longitudinal profile of impairments of body functions and activity limitations of the arm, and to evaluate potential predictors of difficulty caring for the profoundly affected arm poststroke.nnnDESIGNnProspective cohort study.nnnSETTINGnStroke services.nnnPARTICIPANTSnPeople unlikely to regain functional use of the arm (N=155) were recruited at 2 to 4 weeks poststroke, and followed up at 3, 6, and 12 months. Potential predictors at baseline were hypertonicity, pain, motor control, mood, sensation/perception, age, and stroke severity.nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnDifficulty caring for the arm (Leeds Arm Spasticity Impact Scale), pain, hypertonicity, range of movement, arm function, and skin integrity. Multivariable linear regression identified the best fitting model for predicting Leeds Arm Spasticity Impact Scale score at 12 months.nnnRESULTSnThere were 110 participants (71%) reviewed at 1 year. There was a large variation in the profile of arm functions and activity limitations. Inability or severe difficulty caring for the arm affected 29% of participants. Hypertonicity developed in 77%, with severe hypertonicity present in 25%. Pain was reported by 65%, 94% developed shoulder contracture, and 6% had macerated skin. Difficulty caring for the arm increased with age, greater level of hypertonicity, and stroke classification; collectively, these factors accounted for 33% of the variance in Leeds Arm Spasticity Impact Scale scores.nnnCONCLUSIONSnAt 1 year poststroke, there was a high incidence of impairments of body functions and activity limitations in people with a profoundly affected arm. Individual profiles were very variable and although some predisposing factors have been identified, it remains difficult to predict who is at greatest risk.