Matteo Paci

Motor and functional recovery in patients with post-stroke depression

Purpose: Depression is very common following stroke. Correlation between post-stroke depression (PSD) and functional outcome has been shown, but differential impact both on functional and motor recovery has not been deeply investigated. This study evaluates the influence of PSD on motor and functional outcome. Method: One hundred and seventeen acute stroke patients were selected in an intensive rehabilitation department, and divided into two groups according to the presence of PSD (PSD + and PSD −). Screening measures were DSM-IV criteria, the Geriatric Depression Scale and the Cornell Scale. Outcomes were evaluated on the basis of the Barthel Index (BI) and the Fugl – Meyer Assessment Scale (FMA). Measurements were performed at admission to the department (T1), discharge (T2) and follow up (T3) in a whole period of 3 months from stroke. Results: Both groups showed a significant improvement in all outcome measures. Improvement differences were not significant on FMA scores in either group at each assessment; the PSD group had a significant higher improvement on BI score at follow-up. According to the logistic model, from T1 to T2 and from T1 to T3, only motor recovery shows a significant relation with functional recovery; from T2 to T3 PSD is the only significant factor related to functional recovery. Conclusions: PSD is not an influencing factor for motor recovery. Results show a negative impact of PSD on the functional recovery process after discharge and not during hospitalisation. Discharge appears to be a critical step for management of PSD.

Glenohumeral subluxation in hemiplegia: An overview.

This review summarizes the recent advances in glenohumeral subluxation (GHS) in hemiplegic patients and analyzes the reliability and validity of clinical evaluation and the effectiveness of different treatment approaches. GHS, a common complication of stroke, can be considered an important risk factor for shoulder pain and other problems. GHS is a complex phenomenon, and its pathomechanics are not yet fully understood. Radiographic measurements are considered the best method of quantifying GHS. Clinical evaluation can be useful as screening assessment. Functional electrical stimulation and strapping are effective in an acute stage of hemiplegia; some types of slings have been shown to be effective and may be used together with other strategies.

Physiotherapy for pusher behaviour in a patient with post-stroke hemiplegia.

OBJECTIVE This case report describes a specific, literature-based physiotherapy treatment and the outcome for a stroke patient with pusher behaviour. Pusher behaviour is characterized by pushing strongly towards the hemiplegic side in all positions and resisting any attempt at passive correction of posture to bring the weight towards or over the midline of the body. METHODS The patient was a 71-year-old man with clear pusher behaviour due to a stroke. Therapy for the pushing behaviour was performed over a 3-week period. Motor function, mobility, disability, tone anomalies and pusher behaviour were assessed before and after the study period. Immediate effects of a single training session were assessed by clinical observation. RESULTS AND CONCLUSION Immediate effects on the pusher behaviour were observed when using visual and auditory feedback, but not when somatosensory input was used. These results were not maintained to the end of the treatment period. Treatment makes the patient able to use compensatory strategies for functional activities. The long-term effects should be investigated in more depth in the future.

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.

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.

Recovery from stroke in patients with diabetes mellitus.

BACKGROUND AND AIM Diabetes mellitus (DM) is recognized as an important risk factor for stroke and might theoretically influence post-stroke level of disability, increasing the extension of the cerebral injured area. However, results of the few researches aimed at studying this influence are contradictory; moreover, the effect of DM on motor recovery has not been extensively studied. The aim of this study was to investigate the effect of DM on both functional and motor recovery. METHODS A total of 395 acute patients with first stroke were selected in a rehabilitation department and divided into two groups on the basis of the presence or absence of DM (DM+ and DM-, respectively). Outcome measures were the Barthel Index, the Fugl-Meyer Assessment Scale, and the mobility part of the motor assessment chart according to Lindmark and Hamrin. Participants were assessed at admission to department (T1, 13.9+/-7.9 days from stroke onset), at discharge (T2, 40.1+/-13.4), and at follow-up (T3, 84.2+/-14.3). A 2 x 3 analysis of variance with repeated measures was performed to verify the effect of group and of phase of assessment on motor and functional measures and their interaction. RESULTS DM+ and DM- groups included 93 and 302 patients, respectively. Both groups showed a significant and progressive improvement in all outcome measures (P<.001), but no interaction was found between group and phase of assessment, which means that motor and functional recovery was similar in the two groups. CONCLUSION Results suggest that diabetes has no influence on motor and functional outcome within the acute and post-acute phase after stroke. Further research should investigate motor recovery in a longer-term period and with larger samples.