Mark A. Hirsch

Computerized gait analysis in Legg Calvé Perthes disease—Analysis of the frontal plane

UNLABELLED Current follow-up- and outcome-evaluations of Legg-Calvé-Perthes disease (LCPD) are based on subjective measures of function, clinical and radiological parameters. The objective of this study was to evaluate the sagittal plane kinematics and the effect on hip joint loading on the affected hip in children with LCPD. MATERIALS AND METHODS Computerized gait analysis was performed in 49 LCPD patients aged ≥ 5 years with unilateral hip involvement. Sagittal plane kinematics and kinetics were compared to a group of healthy children (n=30). RESULTS Kinematics: a significantly increased anterior tilt and range of motion (ROM) of the pelvis combined with a marked reduction of the extension of the involved hip joint compared to the control group was observed. The increased ROM of the contralateral hip results from increased maximum flexion. Power generation: overall significantly decreased on the involved side during florid stage. Global hip function: significantly reduced hip flexor index of the involved hip; 46.2% of the patients in advanced stage, although having no significant changes in kinematics - except increased anterior pelvic tilt - had a pathologic HFI. CONCLUSION Sagittal plane hip function is significantly impaired in florid and advanced LCPD. The results of this study will lead to further investigations into whether this development can be prevented by conservative or operative treatment thus improving function and long-term prognosis.

Exercise-induced neuroplasticity in human Parkinson's disease: What is the evidence telling us?

INTRODUCTION While animal models of exercise and PD have pushed the field forward, few studies have addressed exercise-induced neuroplasticity in human PD. METHOD As a first step toward promoting greater international collaboration on exercise-induced neuroplasticity in human PD, we present data on 8 human PD studies (published between 2008 and 2015) with 144 adults with PD of varying disease severity (Hoehn and Yahr stage 1 to stage 3), using various experimental (e.g., randomized controlled trial) and quasi-experimental designs on the effects of cognitive and physical activity on brain structure or function in PD. We focus on plasticity mechanisms of intervention-induced increases in maximal corticomotor excitability, exercise-induced changes in voxel-based gray matter volume changes and increases in exercise-induced serum levels of brain derived neurotrophic factor (BDNF). Finally, we provide a future perspective for promoting international, collaborative research on exercise-induced neuroplasticity in human PD. CONCLUSION An emerging body of evidence suggests exercise triggers several plasticity related events in the human PD brain including corticomotor excitation, increases and decreases in gray matter volume and changes in BDNF levels.

Marital adjustment and stability following traumatic brain injury: a pilot qualitative analysis of spouse perspectives.

Background:Traumatic brain injury (TBI), causing various impairments and functional changes, may adversely impactmarital relationships. However, dynamics of the interactions that contribute to these marital difficulties are complex and poorlyunderstood. There has been little research on marital quality and stability in families of a person with TBI. Objective:Byidentifying themes of marital adjustment and stability, this qualitative exploratory study examines how a spouse who has experienced TBIaffects the marital relationship. Methods:Two gender-specific focus groups, each with 5 spouses of individuals living withthe effects of TBI, were conducted to collect data on marital interactions that were analyzed for themes related to marital adjustmentand stability. The data were analyzed using grounded theory, and then relational theories were applied as a framework for organizing themetacodes and concepts. Results:This study suggests that, after TBI, changes in family dynamics and the way spousesperceive those dynamics affect movement toward pulling together or pulling apart. Conclusion:Changes in spousalperceptions, interactions, responsibilities, and reactions to brain injury may impact marital stability and satisfaction. Further studyis warranted to better understand and determine whether and how awareness of these changes may be incorporated into treatment.

Assessment of primary care services and perceived barriers to care in persons with disabilities.

Harrington AL, Hirsch MA, Hammond FM, Norton HJ, Bockenek WL. Assessment of primary care services and perceived barriers to care in persons with disabilities. Objective:To determine what percentage of persons with disabilities have a primary care provider, participate in routine screening and health maintenance examinations, and identify perceived physical or physician barriers to receiving care. Design:A total of 344 surveys, consisting of 66 questions, were collected from adults with disabilities receiving care at an outpatient rehabilitation clinic. Results:A total of 89.5% (95% CI 86.3%–92.8%) of participants reported having a primary care physician. Younger persons (P < 0.0001), men (P < 0.02), persons with brain injury (P < 0.05), or persons with amputations (P < 0.05) were less likely to have a primary care physician. Participant report of screening for alcohol, nonprescription drug use, and safety with relationships at home ranged from 26.6% to 37.5% compared with screening for depression, diet, exercise, and smoking (64.5%–70%). Completion rates of age- and gender-appropriate health maintenance examinations ranged from 42.4% to 90%. A total of 2.67% of participants reported problems with physical access at their physician’s office, and 36.4% (95% CI 30.8%–42.1%) of participants reported having to teach their primary care physician about their disability. Conclusions:Most persons with disabilities have a primary care physician. In general, completion rates for routine screening and health maintenance examinations were high. Perceived deficits in primary care physicians’ knowledge of disability issues seem more prevalent than physical barriers to care.

Factors Associated With Discharge to Home Versus Discharge to Institutional Care After Inpatient Stroke Rehabilitation

OBJECTIVE To examine sociodemographic and clinical characteristics independently associated with discharge home compared with discharge to a skilled nursing facility (SNF) after acute inpatient rehabilitation. DESIGN Retrospective cohort study. SETTING Three tertiary accredited acute care rehabilitation facilities. PARTICIPANTS Adult patients with stroke (N=2085). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS Of 2085 patients with stroke treated at 3 centers over a 4-year period, 78.2% (n=1631) were discharged home and 21.8% (n=454) discharged to an SNF. Findings from a multivariable logistic regression analysis indicated that patients were less likely to be discharged home if they were older (odds ratio [OR], .98; 95% confidence interval [CI], .96-.99), separated or divorced (compared with married; OR, .61; 95% CI, .48-.79), or with Medicare health insurance (compared with private insurance; OR, .69; 95% CI, .55-.88), or had dysphagia (OR, .83; 95% CI, .71-.98) or cognitive deficits (OR, .79; 95% CI, .77-.81). The odds of being discharged home were higher for those admitted with a higher motor FIM score (OR, 1.10; 95% CI, 1.09-1.11). The following were not associated with discharge disposition: sex, race, prestroke vocational status, availability of secondary health insurance, number of days from stroke onset to rehabilitation facility admission, stroke type, impairment group, cognitive FIM on admission, other stroke deficits (aphasia, ataxia, neglect, or speech disturbance), stroke complications of hyponatremia or urinary tract infection, or comorbid conditions. CONCLUSIONS One in 5 patients with stroke were discharged to an SNF after inpatient rehabilitation. On admission, several sociodemographic and clinical characteristics were identified that could be considered as important factors in early discussions for discharge planning.

Community-based rehabilitation for Parkinson's disease: from neurons to neighborhoods.

This paper describes a model for developing early, community-based exercise interventions for people with Parkinsons disease (PD). The model being described is novel in that it advocates collaborative development of the program by multiple stakeholders (i.e., researchers, people with Parkinsons disease, caregivers, Parkinsons associations and healthcare providers), utilizing a community-based participatory research (CBPR) approach, and peer-to-peer training by caregivers and persons with PD. Opportunities and challenges of creating community-based exercise programs are discussed.

Harnessing Cueing Training for Neuroplasticity in Parkinson Disease

Despite advances in pharmacologic management, deficits in gait and gait-related activities remain persistent in Parkinson disease (PD), resulting in reduced safety and ADL independence. Alternative rehabilitative allied health approaches to the management of these problems, such as physical therapy or exercise training, are, therefore, important. We summarize literature on neuroprotective and neurorestorative effects of physical exercise. Next, we discuss data on the importance of exercise training with external rhythmic cues and summarize literature, demonstrating usefulness of goal-based exercise training with external cues on gait and gait-related activities in PD. The underlying mechanisms of cueing-induced neuroplasticity in PD are still unclear. It is also unclear whether cueing training can elicit neuroplastic effects comparable with those of regular exercise. Throughout this article, we maintain the following data-driven observations: (1) physical exercise can decrease the risk of later-developing PD, and evidence from animal studies suggests that neuronal cell death in the substantia nigra can be prevented through an exercise-induced increase in neurotrophic factors; (2) physical exercise has the potential to mitigate the effects of PD through an enhanced efficiency of dopamine transmission; (3) all modalities of cueing training can improve gait and gait-related activities in PD; (4) although no direct evidence for neuroprotective or neurorestorative effects of cueing training can be found, we predict that compensatory mechanisms play a role in cueing training, since externally triggered movements are thought to bypass the affected basal ganglia circuitry and activate the premotor cortex, cerebellum, and parietal cortex; and (5) learning-related improvements in motor function as a result of cueing training are likely to be accompanied by neuronal adaptations. The immediate effects of cueing training may relate to compensatory neuronal pathways that are not directly involved during regular exercise. We pose that external cueing facilitates the conditions for goal-based exercise training to improve gait and gait-related activities of patients with PD. The improved motor performance may result in increased exercise capacity and daily physical activity and as such indirectly affect neuroprotective and neurorestorative mechanisms comparable with regular exercise.

Parkinson patients as partners in care

Increasing physical activity, as part of an active lifestyle, is an important health goal for individuals with Parkinsons disease (PD). Exercise can positively impact health related quality of life. Given this, how can we promote physically active lifestyles among PD patients (most of whom are sedentary)? Here we suggest that health care professionals could significantly expand their impact by collaborating with PD patients and their spouses (or caregivers) as partners-in-care. We outline reasons why partners-in-care approaches are important in PD, including the need to increase social capital, which deals with issues of trust and the value of social networks in linking members of a community. We then present results of a qualitative study involving partners-in-care exercise beliefs among 19 PD patients and spouses, and conclude with our perspective on future benefits of this approach.

Receipt of dental care and barriers encountered by persons with disabilities

A study was conducted to describe the receipt of dental care by patients with disabilities and to understand their perspective with regard to barriers to dental care. Subjects for this study were recruited among patients with disabilities seen at Carolinas Rehabilitations outpatient clinic. A questionnaire consisting of 66 questions was completed by 344 subjects; with the topics related to both medical and dental care. Among the study population, 57.2% of subjects reported being seen by a dentist within the last 12 months, versus 67.3% before they became disabled. The last dental appointment was a routine examination for 59.5% of the respondents. Since becoming disabled, 16.6% of subjects reported problems receiving dental care. Financial challenges were the primary problem followed by physical accessibility issues. Further research is required to discover how barriers to care can be overcome to assure that those with disabilities receive adequate dental care.

Relational dimension of irritability following traumatic brain injury: A qualitative analysis

Background: Irritability is a common long-term sequelae of traumatic brain injury (TBI). In a prior study on TBI irritability, relational interactions were one of four dimensions of irritability occurrence and precipitation. This present analysis examines these same data in greater detail. Methods: Fifty focus group transcripts from a study on irritability were re-analysed to examine: (1) irritability in spousal relationships following TBI, (2) retrospective accounts of spousal interactions contributing to irritability and (3) impact of irritability on marital relationships. Grounded Theory was used to develop themes, metacodes and theories. Results: Several theories emerged regarding irritability with respect to spousal relations, all based on the overarching theory that irritability in people with TBI has a strong relational component involved in triggering, experiencing and preventing irritability. Sub-theories supporting this include: (1) irritability breeds further irritability, (2) spousal responses can trigger irritability among persons with TBI and vice versa, (3) difficulties making emotional connections may incite negative interactions, (4) expectations of others may contribute to irritable behaviour, and (5) communication breakdowns may provoke irritability. Conclusions: Irritability associated with TBI resides in the family system as well as the individual. In treating irritability one should include comprehensive assessment and assistance to improve interpersonal interactions.