Marco Baccini

Efficacy of physiotherapy interventions late after stroke: a meta-analysis

Objective Physiotherapy is usually provided only in the first few months after stroke, while its effectiveness and appropriateness in the chronic phase are uncertain. The authors conducted a systematic review and meta-analysis of randomised clinical trials (RCT) to evaluate the efficacy of physiotherapy interventions on motor and functional outcomes late after stroke. Methods The authors searched published studies where participants were randomised to an active physiotherapy intervention, compared with placebo or no intervention, at least 6 months after stroke. The outcome was a change in mobility and activities of daily living (ADL) independence. The quality of the trials was evaluated using the PEDro scale. Findings were summarised across studies as effect size (ES) or, whenever possible, weighted mean difference (WMD) with 95% CI in random effects models. Results Fifteen RCT were included, enrolling 700 participants with follow-up data. The meta-analysis of primary outcomes from the original studies showed a significant effect of the intervention (ES 0.29, 95% CI 0.14 to 0.45). The efficacy of the intervention was particularly evident when short- and long-distance walking were considered as separate outcomes, with WMD of 0.05 m/s (95% CI 0.008 to 0.088) and 20 m (95% CI 3.6 to 36.0), respectively. Also, ADL improvement was greater, though non-significantly, in the intervention group. No significant heterogeneity was found. Interpretation A variety of physiotherapy interventions improve functional outcomes, even when applied late after stroke. These findings challenge the concept of a plateau in functional recovery of patients who had experienced stroke and should be valued in planning community rehabilitation services.

Subtle Neurological Abnormalities as Risk Factors for Cognitive and Functional Decline, Cerebrovascular Events, and Mortality in Older Community-Dwelling Adults

BACKGROUND Subtle, but clinically detectable, neurological abnormalities (SNAs) are associated with impaired physical performance in elderly persons without overt neurological diseases. We investigated whether SNAs were prospectively associated with cognitive and functional status, death, and cerebrovascular events (CVEs) in older community-dwelling individuals. METHODS In participants without history of stroke, parkinsonism and dementia, or cognitive impairment, a score (N(SNA)) was obtained by summing SNAs detected with a simple neurological examination. Cognitive status and disability were reassessed 4 years later, and deaths and CVEs were documented over 8 years. RESULTS Of 506 participants free of neurological diseases (mean [SEM] age, 71.9 [0.3] years; 42% were men), 59% had an N(SNA) of 1 or more (mean [SEM], 1.1 [0.06]; range, 0-8). At baseline, the N(SNA) increased with age and with declining cognitive and physical performance, depressive symptoms, and disability, after adjusting for several covariates, but did not increase with falls and urinary incontinence. The N(SNA) prospectively predicted worsening cognitive status and disability, adjusting for demographics and for baseline comorbidity and cognitive and physical performance. The mortality rates were 22.6, 23.3, 23.9, 58.6, and 91.9 per 1000 person-years in participants with an N(SNA) of 0, 1, 2, 3, and 4 or higher, respectively. Compared with an N(SNA) of less than 3, having an N(SNA) of 3 or higher was associated with an increased adjusted risk of death (hazard ratio, 1.77; 95% confidence interval [CI], 1.25-2.74) and of CVE (hazard ratio, 1.94; 95% CI, 1.07-3.54) over 8 years. CONCLUSION In this sample of older community-dwelling persons without overt neurological diseases, multiple SNAs were associated with cognitive and functional decline and independently predicted mortality and CVEs.

Tools for Observational Gait Analysis in Patients With Stroke: A Systematic Review

Background Stroke severely affects walking ability, and assessment of gait kinematics is important in defining diagnosis, planning treatment, and evaluating interventions in stroke rehabilitation. Although observational gait analysis is the most common approach to evaluate gait kinematics, tools useful for this purpose have received little attention in the scientific literature and have not been thoroughly reviewed. Objectives The aims of this systematic review were to identify tools proposed to conduct observational gait analysis in adults with a stroke, to summarize evidence concerning their quality, and to assess their implementation in rehabilitation research and clinical practice. Methods An extensive search was performed of original articles reporting on visual/observational tools developed to investigate gait kinematics in adults with a stroke. Two reviewers independently selected studies, extracted data, assessed quality of the included studies, and scored the metric properties and clinical utility of each tool. Rigor in reporting metric properties and dissemination of the tools also was evaluated. Results Five tools were identified, not all of which had been tested adequately for their metric properties. Evaluation of content validity was partially satisfactory. Reliability was poorly investigated in all but one tool. Concurrent validity and sensitivity to change were shown for 3 and 2 tools, respectively. Overall, adequate levels of quality were rarely reached. The dissemination of the tools was poor. Conclusions Based on critical appraisal, the Gait Assessment and Intervention Tool shows a good level of quality, and its use in stroke rehabilitation is recommended. Rigorous studies are needed for the other tools in order to establish their usefulness.

Scale for Contraversive Pushing: Cutoff Scores for Diagnosing “Pusher Behavior” and Construct Validity

Background and Purpose: Considerable disagreement exists among researchers with regard to the prevalence, pathophysiology, and treatment of “pusher behavior” (PB), partly because of different testing procedures. This study was primarily aimed at establishing cutoff scores for and the construct validity of the Scale for Contraversive Pushing (SCP). The prevalence of PB in people with right- and left-brain lesions also was investigated. Subjects and Methods: The study subjects were 105 consecutive patients with recent stroke. Two methods were used to diagnose PB: clinical examination and SCP score with 3 different cutoff points—an SCP total score of greater than 0 (Crit_1), subscores in each section of the scale of greater than 0 (Crit_2), and subscores in each section of the scale of ≥1 (Crit_3). Clinical and SCP diagnoses were independently made by different examiners. The Cohen κ coefficient was used to determine the agreement between clinical and SCP diagnoses. The construct validity of the SCP was estimated by calculation of Spearman rank correlation coefficients for SCP and balance, mobility, and functional scores. Results: The agreement between clinical and SCP diagnoses was low (κ=.212) when Crit_1 was used. Crit_2 led to the highest agreement with the clinical diagnosis (κ=.933). However, only Crit_3, although globally less accurate (κ=.754), ensured no false-positive results. The construct validity of the SCP was demonstrated by significant (P<.001) moderate to high correlations with mobility (rho=.595), functional (rho=.632), and balance (rho=.666) scores. The prevalence of PB was not influenced by the side of the lesion. A limitation of the study was that the reliability of the clinical examination method was not investigated. Discussion and Conclusion: The results support the validity of the SCP and suggest the need to choose different SCP cutoff criteria (Crit_2 or Crit_3) according to the aim of the evaluation.

The Scale for Contraversive Pushing: A Reliability and Validity Study

Objective. Pushing toward the hemiplegic side can interfere with mobility training after stroke. This study estimated the internal consistency, interrater reliability, and validity of the Scale for Contraversive Pushing (SCP). Methods. Twenty-six patients with recent stroke were diagnosed with pusher behavior (PB). Two testers, randomly selected from 3 other examiners, independently assessed each patient using the SCP on the same day within 3 days of admission for rehabilitation. Cohen kappa coefficient was used to determine the agreement between the clinical and SCP diagnosis. The interrater reliability of the scale was estimated by calculation of the intraclass correlation coefficient. Cronbach’s alpha coefficient and Pearson’s coefficients were used to estimate the internal consistency of the scale and correlations between the subscores and the total score. Results. The agreement between SCP and clinical diagnosis was very low when the original cutoff criterion for SCP diagnosis was used but was almost perfect with a modified criterion. The interrater reliability was good to excellent with regard both to each sub-score and to the total score. The internal consistency was very high, along with correlations between subscores and total score of the scale. Conclusions. The results provide support for use of the SCP based on its reliability and validity using a modified cutoff criterion to make a diagnosis of PB.

Different motor tasks impact differently on cognitive performance of older persons during dual task tests

BACKGROUND Dual task paradigm states that the introduction of a second task during a cognitive or motor performance results in a decreased performance in either task. Treadmill walk, often used in clinical applications of dual task testing, has never been compared to overground walk, to ascertain its susceptibility to interference from a second task. We compared the effects of overground and treadmill gait on dual task performance. METHODS Gait kinematic parameters and cognitive performance were obtained in 29 healthy older adults (mean age 75 years, 14 females) when they were walking freely on a sensorized carpet or during treadmill walking with an optoelectronic system, in single task or dual task conditions, using alternate repetition of letters as a cognitive verbal task. FINDINGS During overground walking, speed, cadence, step length stride length, and double support time (all with P value<0.001) and cognitive performance (number of correct words, P<0.001) decreased substantially from single to dual task testing. When subjects walked at a fixed speed on the treadmill, cadence decreased significantly (P=0.005), whereas cognitive performance remained unaffected. INTERPRETATION Both motor and cognitive performances decline during dual task testing with overground walking. Conversely, cognitive performance remains unaffected in dual task testing on the treadmill. In the light of current dual task paradigm, these findings may have relevant implication for our understanding of motor control, as they suggest that treadmill walk does not involve brain areas susceptible to interference from the introduction of a cognitive task.

Reported quality of randomized controlled trials in neglect rehabilitation

The aim of this study is to assess the reported quality of randomized controlled trials (RCTs) on the effectiveness of neglect rehabilitation using a standardized scale. A search of seven electronic databases was carried out. Selected articles were scored using the PEDro scale and classified as high or low quality study both with the original cut off of 6 and a modified cut off of 5. A linear regression analysis between year of publication and quality rate was used to test whether the quality of the studies improved with time. A total of 18 RCTs were selected. Six articles (33.3%) and 10 articles (55.56%) were classified as having high quality when the original cut off or the modified cut off of the PEDro scale were used, respectively. Analysis shows no time-related changes in PEDro scores. The results show that reported quality is moderate for RCTs in neglect rehabilitation.

The assessment of subjective visual vertical: comparison of two psychophysical paradigms and age-related performance

Perception of the subjective visual vertical (SVV) is usually assessed by asking to subjects, in complete darkness, to adjust the position of a luminous rod that is variably tilted (i.e., by the method of adjustment [ADJ]). Conversely, the two-alternative forced choice (2AFC) method requires subjects to categorize, as tilted either clockwise (CW) or counterclockwise (CCW), stimuli that are presented on a computer screen and are variably tilted from vertical. In this study, we aimed to compare the results of these two methods and investigate age-related effects on the SVV. SVV was assessed in 102 healthy individuals, 50 women and 52 men, with a mean age of 45.7 (range 20–91), using both ADJ (ten trials, initial 1°, 2°, 4°, 8°, or 12° bar tilts both CW and CCW) and 2AFC (120 stimuli with a 1°–32° variable tilt). Also, 50 of the subjects performed the ADJ test twice, with different bar lengths. We estimated bias and threshold for the two methods, and found that neither measure differed across the methods. Age was a significant predictor of threshold (2AFC, R2 = .141; ADJ, R2 = .190; p < .001), implying lower sensitivity with increasing age. Moreover, the ADJ method showed a significant increase of bias when the initial tilt was farthest from vertical, whereas the rod length was irrelevant. SVV measures obtained with the ADJ and 2AFC methods were comparable, but the latter measures were more resistant to artifacts that might affect the measurement. The lower sensitivity found in older persons may have an influence on their ability to interact with the environment and may contribute to impairment of postural control.

Pusher behaviour: a critical review of controversial issues.

Despite an increasing interest by researchers and clinicians, the pusher behaviour (PB) is still a poorly understood disorder, exhibited by some stroke patients, who push with their non-affected limbs towards the contralesional side and resist attempts at correction of their tilted posture. This review is aimed at critically summarizing findings on controversial issues regarding PB, namely correlation with neglect, neural correlates and underlying mechanisms. There is a growing agreement that PB reflects some misrepresentation of verticality. According to different findings, it has been suggested that PB may result from a conflict between an intact visual and an impaired somesthetic perception of vertical, or alternatively that it might result from a high-order disruption of somesthetic information processing from the paretic hemi-body, named graviceptive neglect. Although conflicting data have been reported, the association between PB and neglect seems to be confirmed, when a comprehensive assessment of neglect-related phenomena is performed. Localization of brain lesions is also controversial. Some investigations stressed the role of posterior lateral thalamus, but other findings revealed that different lesional sites may also be present. On the basis of these data we suggest the existence of a multicomponential network reliable for upright posture control. This model might also explain some different results in this area. Clinical implications and requirements for future research are discussed.

Instructions for the Clinical Scale for Contraversive Pushing (SCP)

To the Editor: We would like to thank Drs Baccini, Paci, and Rinaldi (Neurorehabil Neural Repair 2006;20: 468-472) for their thorough analysis of reliability and validity of our Clinical Scale for Contraversive Pushing (SCP). This scale may help diagnose and quantify the behavior of patients with stroke and left or right brain damage who demonstrate the “pusher syndrome”—a behaviour in which patients actively push away from the nonhemiparetic side, leading to a loss of postural balance. Without empirical knowledge about appropriate cutoff scores for the SCP, we tentatively suggested a criterion that was based only on our daily clinical experience and conservative enough to avoid false-positive diagnoses as long as no empirical data on reliable cutoff scores were available. We are delighted that Baccini and coworkers have filled this gap. The authors selected 26 patients who had a hemiparesis and postural asymmetry. Their observed cutoff criterion (all 3 SCP variables >0) in this selected patients group now requires further investigation to avoid false-positive diagnoses in an unselected group of stroke patients (ie, those who typically present to a department of general neurology). The SCP investigates 3 variables: (1) spontaneous body posture, (2) the use of the nonparetic extremities to bring about the pathological lateral tilt of the body axis, and (3) resistance to passive correction of tilted posture. Baccini and colleagues rightly mention that in our original description of the scale, no details were provided about how to test subjects’ use of the nonparetic extremities to bring about the pathological lateral tilt (SCP variable B) before grading them. They speculated that more detailed instructions, with the explicit definition of the tasks to be used to explore changes of position, could enhance the scale’s validity as a diagnostic tool for pusher syndrome. We agree and would like to complement instruction and task definitions for SCP variable B as follows: abduction and extension of the nonparetic extremities should be assessed in 2 steps. With the patient sitting on the bedside, the examiner first observes whether the ipsilesional extremities are spontaneously abducted from the body, searching for contact with the surface (arm/hand on mattress; leg/foot on floor), and show activity to achieve extension of the elbow and/or the knee and hip joints. If so, variable B is given the value 1 for sitting. If abduction and extension of the nonparetic extremities are not spontaneously performed, the examiner asks the patient to (1) glide the buttocks on the mattress toward the nonparetic side and/or (2) change sitting position from bed to wheelchair toward the nonparetic side. In the latter case, the buttocks are lifted just enough to pass over the tires of the wheelchair. The patient then has to master a small swinging movement of the buttocks to change seats. The examiner observes whether, in at least 1 of these 2 situations of position change ((1) or (2) above), the ipsilesional extremities are abducted from the body and show activity to achieve extension of the elbow and/or the knee and hip joints. If so, variable B is given the value 0.5 for sitting. The examination continues with the patient standing. The examiner first observes whether the ipsilesional leg is spontaneously (already when rising from the sitting position) abducted and extended. If so, variable B is given the value 1 for standing. If abduction and extension of the nonparetic leg are not spontaneously performed, the examiner asks the patient to start walking. The examiner observes whether the patient now abducts and extends the ipsilesional leg. If so, variable B is given the value 0.5 for standing.