L. Roncari

Pathophysiology of Motor Dysfunction in Parkinson’s Disease as the Rationale for Drug Treatment and Rehabilitation

Cardinal motor features of Parkinsons disease (PD) include bradykinesia, rest tremor, and rigidity, which appear in the early stages of the disease and largely depend on dopaminergic nigrostriatal denervation. Intermediate and advanced PD stages are characterized by motor fluctuations and dyskinesia, which depend on complex mechanisms secondary to severe nigrostriatal loss and to the problems related to oral levodopa absorption, and motor and nonmotor symptoms and signs that are secondary to marked dopaminergic loss and multisystem neurodegeneration with damage to nondopaminergic pathways. Nondopaminergic dysfunction results in motor problems, including posture, balance and gait disturbances, and fatigue, and nonmotor problems, encompassing depression, apathy, cognitive impairment, sleep disturbances, pain, and autonomic dysfunction. There are a number of symptomatic drugs for PD motor signs, but the pharmacological resources for nonmotor signs and symptoms are limited, and rehabilitation may contribute to their treatment. The present review will focus on classical notions and recent insights into the neuropathology, neuropharmacology, and neurophysiology of motor dysfunction of PD. These pieces of information represent the basis for the pharmacological, neurosurgical, and rehabilitative approaches to PD.

Relationship Between Ultrasonographic, Electromyographic, and Clinical Parameters in Adult Stroke Patients With Spastic Equinus: An Observational Study

OBJECTIVE To find more accurate indices that could affect decisions in spasticity treatment by investigating the relation between ultrasonographic, electromyographic, and clinical parameters of the gastrocnemius muscle in adults with spastic equinus after stroke. DESIGN Observational study. SETTING University hospitals. PARTICIPANTS Chronic patients with stroke with spastic equinus (N=43). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Ultrasonographic features were spastic gastrocnemius muscle echo intensity, muscle thickness, and posterior pennation angle of the gastrocnemius medialis (GM) and gastrocnemius lateralis (GL) in both legs. Electromyographic evaluation included compound muscle action potentials (CMAPs) recorded from the GM and GL of both legs. Clinical assessment of the spastic gastrocnemius muscle was performed with the Modified Ashworth Scale (MAS) and by measuring ankle dorsiflexion passive range of motion (PROM). RESULTS Spastic muscle echo intensity was inversely associated with proximal (GM and GL: P=.002) and distal (GM and GL: P=.001) muscle thickness, pennation angle (GM: P< .001; GL: P=.01), CMAP (GM: P=.014; GL: P=.026), and ankle PROM (GM: P=.038; GL: P=.024). The pennation angle was directly associated with the proximal (GM and GL: P< .001) and distal (GM: P=.001; GL: P< .001) muscle thickness of the spastic gastrocnemius muscle. The MAS score was directly associated with muscle echo intensity (GM: P=.039; GL: P=.027) and inversely related to the pennation angle (GM and GL: P=.001) and proximal (GM: P=.016; GL: P=.009) and distal (GL: P=.006) muscle thickness of the spastic gastrocnemius. CONCLUSIONS Increased spastic muscle echo intensity was associated with reduced muscle thickness, posterior pennation angle, and CMAP amplitude in the gastrocnemius muscle. Building on previous evidence that these instrumental features are related to botulinum toxin response, these new findings may usefully inform spasticity treatment decisions.

Combined effects of transcranial direct current stimulation (tDCS) and transcutaneous spinal direct current stimulation (tsDCS) on robot-assisted gait training in patients with chronic stroke: A pilot, double blind, randomized controlled trial

PURPOSE Preliminary evidence has shown no additional effects of transcranial direct current stimulation (tDCS) on robotic gait training in chronic stroke, probably due to the neural organization of locomotion involving cortical and spinal control. Our aim was to compare the combined effects of tDCS and transcutaneous spinal direct current stimulation (tsDCS) on robotic gait training in chronic stroke. METHODS Thirty chronic stroke patients received ten 20-minute robot-assisted gait training sessions, five days a week, for 2 consecutive weeks combined with anodal tDCS + sham tsDCS (group 1; n = 10) or sham tDCS + cathodal tsDCS (group 2; n = 10) or tDCS + cathodal tsDCS (group 3; n = 10). The primary outcome was the 6-minute walk test (6MWT) performed before, after, 2 weeks and 4 weeks post-treatment. RESULTS Significant differences in the 6MWT distance were noted between group 3 and group 1 at the post-treatment and 2-week follow-up evaluations (post-treatment P = 0.015; 2-week follow-up P = 0.001) and between group 3 and group 2 (post-treatment P = 0.010; 2-week follow-up P =  .015). No difference was found between group 2 and group 1. CONCLUSIONS Our preliminary findings support the hypothesis that anodal tDCS combined with cathodal tsDCS may be useful to improve the effects of robotic gait training in chronic stroke.

Factors Predicting Functional and Cognitive Recovery Following Severe Traumatic, Anoxic, and Cerebrovascular Brain Damage

Objectives:To compare demographic data, clinical data, and rate of functional and cognitive recovery in patients with severe traumatic, cerebrovascular, or anoxic acquired brain injury (ABI) and to identify factors predicting discharge home. Participants:Three hundred twenty-nine patients with severe ABI (192 with traumatic, 104 with cerebrovascular, and 33 with anoxic brain injury). Design:Longitudinal prospective study of inpatients attending the intensive Rehabilitation Department of the “Sacro Cuore” Don Calabria Hospital (Negrar, Verona, Italy). Main measures:Etiology, sex, age, rehabilitation admission interval, rehabilitation length of stay, discharge destination, Glasgow Coma Scale, Disability Rating Scale (DRS), Glasgow Outcome Scale, Levels of Cognitive Functioning, and Functional Independence Measure. Results:Predominant etiology was traumatic; male gender was prevalent in all the etiologic groups; patients with traumatic brain injury were younger than the patients in the other groups and had shorter rehabilitation admission interval, greater functional and cognitive outcomes on all considered scales, and a higher frequency of returning home. Patients with anoxic brain injury achieved the lowest grade of functional and cognitive recovery. Age, etiology, and admission DRS score predicted return home. Conclusions:Patients with traumatic brain injury achieved greater functional and cognitive improvements than patients with cerebrovascular and anoxic ABI. Age, etiology, and admission DRS score can assist in predicting discharge destination.

ACCURACy Of BOTUlINUM TOxIN TypE A INJECTION INTO ThE fOREARM MUsClEs Of ChRONIC sTROkE pATIENTs wITh sp AsTIC flExED wRIsT AND ClENChED fIsT: MANUAl NEEDlE plACEMENT EVAlUATED UsING UlTRAsONOGRAphy

OBJECTIVE To investigate the accuracy of manual needle placement for injection of botulinum toxin type A into the forearm muscles of adults with spastic flexed wrist and clenched fist as a consequence of stroke. DESIGN Prospective clinical study. PATIENTS A total of 41 adults with chronic stroke who were scheduled to receive botulinum toxin type A injection into the following forearm muscles: flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis and flexor digitorum profundus. METHODS According to Huber & Hecks atlas suggestions on treatment of spasticity with botulinum toxin, surface identification of muscles to inject was performed by means of palpation and anatomical landmarks. Accuracy of needle placement and muscle thickness at the site of needle insertion were assessed using ultrasonography. RESULTS Overall accuracy of manual needle placement evaluated using ultrasonography was 51.2%. Accuracy was significantly higher for the finger flexors than for the wrist flexors (63.4% vs 39.0%). The finger flexors were significantly thicker than the wrist flexors (mean 1.58 vs 0.49 cm). CONCLUSION Instrumental guidance should be used in order to achieve an acceptable accuracy of needle placement when performing botulinum toxin type A injections into the forearm muscles of chronic stroke patients with spastic flexed wrist and clenched fist.