Laura K. Vogtle

What are the concerns of older adults living with epilepsy

PURPOSE The goal of this work was to examine the concerns of living with recurrent seizures as expressed by older adults with epilepsy (OAE). METHODS Thirty-three community-dwelling adults over the age of 60 (mean age=65, range 60-80) were surveyed as to their concerns living with epilepsy. All patients were being treated for intractable partial epilepsy (mean age at seizure onset=37, range 1-77) and all were receiving antiepileptic drugs (AEDs). Patients were given a blank sheet of paper and asked to list any concerns they had about living with epilepsy. Each patient listed his or her concerns in order of importance. RESULTS Twenty-eight different areas of concern were listed by the OAE (range 1-6 per patient). Concerns about driving/transportation (64%) and medication side effects (64%) were the most frequently listed concerns. Other concerns listed by >20% of patients included personal safety (39%), AED costs (29%), employment (26%), social embarrassment (21%), and memory loss (21%). Driving/transportation and AED side effects were the two most important concerns. CONCLUSIONS Quality-of-life issues in OAE appear similar in content to those of younger epilepsy groups. Driving/transportation, role restriction (i.e., grandparenting role), employment, social embarrassment, and safety are major concerns expressed by older adults. However, medication side effects appear more concerning to older adults as compared with earlier studies with younger patients. This study highlights the substantial burden of living with epilepsy in older adults and points to the challenges clinicians have when addressing them.

Cognitive Functioning in Community Dwelling Older Adults with Chronic Partial Epilepsy

Summary:  Purpose: To examine cognitive functioning in community‐dwelling older adults with chronic partial epilepsy and demographically matched healthy older adults.

Pain in adults with cerebral palsy: impact and solutions

Studies of health in adults with cerebral palsy (CP) have identified pain as a significant concern. Investigations regarding incidence, intensity, and location in adults with CP found that increasing age and inactivity appeared to be related to pain. Activity and participation in adults with CP seem to be only moderately affected by presence of pain. Various sources of pain have been identified in adults with CP but have not been well studied. These include orthopedic issues, poor bone mineral density and related fractures, dental and jaw problems, and nutrition‐related pain. Limited healthcare utilization studies suggest that adults with CP use healthcare services, especially preventative and rehabilitative services less, and do not consult physicians regarding pain. Medication solutions for chronic pain are not well studied. Botulinum toxin and intrathecal baclofen have been demonstrated to minimize pain; however, the impact of other medications needs further investigation. Other interventions for pain include small studies examining the use of biofeedback and exercise. Larger studies are needed to establish effectiveness. In order to prevent future generations of adults with CP from experiencing high levels of pain, environmental sources of pain need more specific study, as do interventions that are affordable and easily accessed.

A Preliminary Assessment of the Benefits of the Addition of Botulinum Toxin A to a Conventional Therapy Program on the Function of People With Longstanding Stroke

OBJECTIVE To determine if botulinum toxin type A (BTX-A) combined with therapy can facilitate improved upper-extremity (UE) functional status versus therapy alone. DESIGN Double-blind randomized crossover trial. SETTING Tertiary care outpatient rehabilitation center. PARTICIPANTS Convenience sample of 21 men and women (ages 19-80 y) with stroke more than 6 months after insult who had tone greater than 3 on the Ashworth Scale for 2 joints in the involved UE. INTERVENTION Subjects were consecutively recruited and randomized to a double-blind crossover trial. Subjects received either BTX-A combined with a defined therapy program or placebo injection combined with a therapy program in two 12-week sessions. MAIN OUTCOME MEASURES The primary functional outcome measure was the Motor Activity Log (MAL). Subjects were also assessed on physiologic measures including tone (Ashworth Scale), range of motion, and motor strength. RESULTS Improvements were noted in the functional status of the subjects in both arms of the study as measured by the MAL. All subjects had a significant change in functional status on MAL with therapy (P<.05). The use of BTX-A combined with therapy as compared with therapy only improved the functional status of the subjects on the MAL Quality of Movement subscale (P=.0180, t test) and showed a trend toward significance in the Amount of Use subscale (P=.0605, analysis of variance). Six weeks after treatment, the BTX-A combined with therapy decreased the Ashworth score statistically (P=.0271), but the therapy alone group decreased a similar amount at 6 weeks (P=.0117), indicating that most of the physiologic tone change could be attributed to therapy. After each 12-week period, tone had largely returned to baseline (P>.05). CONCLUSION A focused therapy program showed the most improvement in function in this defined stroke population. BTX-A combined with a focused traditional therapy program slightly enhanced the functional status of stroke subjects beyond that obtained with therapy alone 12 weeks after injection.

Health-related quality of life in senior adults with epilepsy: what we know from randomized clinical trials and suggestions for future research.

OBJECTIVE The goal of this work was to review the randomized controlled trial (RCT) literature on antiepileptic medication effects on health-related quality of life in seniors with epilepsy. METHODS Studies published from 1998 to June 2002 were identified by searching through Medline and the Cochrane Clinical Trials Register. Pre-1998 RCTs identified by Baker et al. [Epilepsia 41 (2003) 1357] were also examined for relevance to the present review. Studies were reviewed if they included a RCT design and included epilepsy patients over the age of 60. RESULTS A total of 85 clinical trials were reviewed. Of the 85 studies reviewed only 37 RCT studies included patients over the age of 60. However, formal quality-of-life outcome assessment was not performed in any of the RCTs that included senior adults, and only six studies provided formal quantitative analyses of AED effects in the form of adverse events incidence and participant withdrawal rates. For the most part, early study withdrawal rates were substantial for seniors and adverse events were very common. Two studies reporting on the cognitive and behavioral effects of study AEDs indicated only modest impact when AED monotherapy was kept at therapeutic levels. CONCLUSIONS Despite growing appreciation for quality-of-life, issues in the management of epilepsy little current empirical guidance is available for elderly with epilepsy. There exists virtually no information on elderly patient preferences and goals for epilepsy treatment outcomes, and available data primarily concerns younger adults. Despite some encouraging preliminary evidence from this review suggesting that conservative AED treatment may have a more favorable quality of life-related outcome, more conclusive statements await further systematic investigation.

The Pediatric Motor Activity Log-Revised: Assessing Real-world Arm Use in Children with Cerebral Palsy

OBJECTIVE Widely accepted models of disability suggest that actual use of an impaired upper extremity in everyday life frequently deviates from its motor capacity, as measured by laboratory tests. Yet, direct measures of real-world use of an impaired upper extremity are rare in pediatric neurorehabilitation. This paper examines how well the Pediatric Motor Activity Log-Revised (PMAL-R) measures this parameter, when the PMAL-R is administered as a structured interview as originally designed. DESIGN Parents of 60 children between 2 and 8 years of age with upper-extremity hemiparesis due to cerebral palsy completed the PMAL-R twice. Additionally, the children were videotaped during play structured to elicit spontaneous arm use. More-affected arm use was scored by masked raters; it was thought to reflect everyday activity since no cues were given about which arm to employ. Testing sessions were separated by 3 weeks, during which 29 children received upper-extremity rehabilitation and 31 did not. RESULTS The PMAL-R had high internal consistency (Cronbachs alpha = .93) and test-retest reliability (r = .89). Convergent validity was supported by a strong correlation between changes in PMAL-R scores and more-affected arm use during play, r(53) = .5, p < .001. CONCLUSIONS The PMAL-R interview is a reliable and valid measure of upper-extremity pediatric neurorehabilitation outcome.

Pain and fatigue consistency in adults with cerebral palsy

Purpose. To examine the consistency of pain and fatigue and describe pain interference with daily activities in ambulatory (AMB) and non-ambulatory (non-AMB) adults with cerebral palsy (CP) over a 3-month period. Method. A repeated measures design with 26 participants (12 AMB, 14 non-AMB) acting as their own controls. Pain and fatigue data were collected once per month for three consecutive months using the FACES pain scale and PedsQL™ Multidimensional Fatigue Scale. Pain interference with daily life was assessed using the Pain Disability Index (PDI). Results. No significant differences were found in maximum pain intensity. AMB reported significantly fewer pain sites in the whole body during month 1 than non-AMB. Fatigue was consistent across months; however, AMB reported significantly more General fatigue. Across groups, significant correlations were found between PDI and General, Resting, and Overall fatigue. Non-AMB exhibited significant correlations between total number of pain sites and General and Cognitive fatigue, as well as PDI and Overall fatigue. For the AMB group, PDI and total number of pain sites were significantly correlated. Conclusions. Pain and fatigue consistently and significantly affect adults with CP. Both factors impact the ability of adults, who have CP, to participate in daily life.

Cognitive functioning over 3 years in community dwelling older adults with chronic partial epilepsy

Little is known about cognitive functioning of older adults with chronic partial epilepsy. We examined cognitive performance of this epilepsy patient group over 2-3 years. Seventeen older adults with epilepsy and 17 healthy older adults were administered measures of overall cognition and verbal memory at baseline and 2-3 years later. At baseline, older adults with epilepsy performed below controls on overall cognition and verbal memory (ps<0.001). These deficits generally remained stable at follow-up, although executive control appeared to decline (p<0.05). Older adults with epilepsy showed a failure to benefit from practice on a verbal memory measure (p=0.017). Older adults with epilepsy demonstrated cognitive deficits that generally are not progressive. A failure to benefit from repeat exposure to a Delayed Recall task could indicate learning deficits. These patients may also progressively lose executive control, possibly as a result of accelerated aging.

Interrater reliability and convergent validity of the American Academy for Cerebral Palsy and Developmental Medicine methodology for conducting systematic reviews

Aim  The aim of this study was to evaluate the interrater reliability and convergent validity of the American Academy for Cerebral Palsy and Developmental Medicine’s (AACPDM) methodology for conducting systematic reviews (group design studies).

Outcomes of an exercise program for pain and fatigue management in adults with cerebral palsy

Abstract Purpose: The purpose of this exploratory pilot study was to examine the effect of exercise on pain and fatigue in adults with CP. Method: Twenty-six participants (12 ambulatory, 14 non-ambulatory; 10 males, 16 females; mean age 42.3 ± 11.2 years) enrolled in a study using a repeated measures design including baseline, intervention and follow-up phases of 12 weeks each; 20 participants completed all phases. Primary outcome measures used were the FACES pain scale, the count of body parts with pain and the PedsQL™ Multidimensional Fatigue Scale. Results: Significant beneficial changes were found in the pain and fatigue scales among the ambulatory participants during the intervention phase. However the beneficial changes diminished during the follow-up phase. Secondary outcomes examined included, pain interference, daily physical activity and health-related quality of life. Conclusion: Study outcomes suggest that exercise may provide some benefit for ambulatory adults with CP. Implications for Rehabilitation Pain and fatigue are secondary conditions experienced by many adults with cerebral palsy which have a significant impact on function and quality of life. Physical activity is an intervention which has been demonstrated to decrease both pain and fatigue in other health conditions. In a relatively small sample, this study demonstrates decreased pain and fatigue after an exercise intervention in ambulatory adults with cerebral palsy.