R. Langton Hewer

Loss of arm function after stroke: measurement, frequency, and recovery

This study aims to establish the frequency of paralysis and other arm problems after stroke; the recovery of lost function; and to compare various tests of the affected arm. Thirteen per cent of the sample had no arm paralysis when first seen within 14 days. At 3 months 24 per cent of survivors had moderate or severe paralysis; 57 per cent could place nine pegs into holes within 50 seconds; 19 per cent had significant sensory disturbance; 5 per cent had shoulder pain; 8 per cent had restricted passive shoulder movement; and 17 per cent had some paralysis of the dominant arm. Between 3 and 6 months, improvement of motor power was seen in 40 per cent of patients, and 13 per cent of patients improved their function. Severity of initial paralysis was an important prognostic factor.

Enhanced physical therapy improves recovery of arm function after stroke. A randomised controlled trial.

Previous research on stroke rehabilitation has not established whether increase in physical therapy lead to better intrinsic recovery from hemiplegia. A detailed study was carried out of recovery of arm function after acute stroke, and compares orthodox physiotherapy with an enhanced therapy regime which increased the amount of treatment as well as using behavioural methods to encourage motor learning. In a single-blind randomised trial, 132 consecutive stroke patients were assigned to orthodox or enhanced therapy groups. At six months after stroke the enhanced therapy group showed a small but statistically significant advantage in recovery of strength, range and speed of movement. This effect seemed concentrated amongst those who had a milder initial impairment. More work is needed to discover the reasons for this improved recovery, and whether further development of this therapeutic approach might offer clinically significant gains for some patients.

Assessment of recovery of arm control in hemiplegic stroke patients. 1. Arm function tests

In a preliminary study a group of hemiplegic patients have been assessed for return of arm function for periods up to 64 weeks after stroke. The assessment procedure employs a few simple and easily performed tests which take into account principles of the central nervous control of movement. The tests are highly repeatable and can be carried out by staff untrained in medicine or any form of physical therapy. Patients have been divided into two groups on the basis of the scores obtained in the tests at 16 weeks after stroke. The group scoring 80% or more are very likely subsequently to recover useful function of the arm and hand. The group of patients scoring less than 80% at 16 weeks after stroke are likely subsequently to recover limited arm movements and little hand movement. The preliminary results would suggest that the tasks provide a guide to prognosis and an indiction of the most suitable type of general physical therapy.

Memory disturbance after stroke: frequency and associated losses.

138 patients who survived an acute stroke had their memory assessed at 3 months. As a group these patients had no impairment of digit span when compared with published age-matched normal data. Immediate logical memory (of a story) was poor in 29 per cent, and 14 per cent could not draw a picture immediately after seeing it. Poor memory function was not associated with more severe strokes, but was associated with poor functional ability on everyday tasks. Poor visual recall was associated with lower abilities at ADL, independent of any effect of age. Statistically significant recovery was detected in immediate logical memory and visual recall between 3 and 6 months.

Assessment of recovery of arm control in hemiplegic stroke patients. 2. Comparison of arm function tests and pursuit tracking in relation to clinical recovery

In a preliminary study, return of arm function in hemiplegic patients has been assessed for periods up to 64 weeks after stroke using two methods of testing. The first method concerns the performance of simple motor tasks involving the arm and hand. The second method is a pursuit tracking task using elbow movements. Patients were divided into two groups depending on whether they scored above 80% (Group I) or below 80% (Group II) on the first method at 16 weeks after stroke. When the two arm assessment methods were compared with clinical assessments for all the patients, general agreement was shown. Among Group I patients there was also significant agreement between the assessments; among Group II patients the agreement was poor. The two arm assessment methods, however, showed mutual agreement. In conclusion, both arm assessments provide a general prediction of the recovery of movement control of patients following stroke.

Effect of the beta adrenergic blocking agent propranolol on essential tremor

A double blind trial of a single 40 mg dose of the beta adrenergic blocking agent propranolol in the treatment of essential tremor produced significant reduction of tremor in four of five patients, but this effect was transient and had considerably diminished within four hours. A months double blind clinical trial of propranolol, in a dose of 30 mg three times a day, showed that the active drug gave statistically better results than placebo for the attenuation of tremor. The mode of action of propranolol in the reduction of essential tremor is probably a dual one, due both to blockage of peripheral beta receptors and to a central depressant effect.

Some applications of human-operator research to the assessment of disability in stroke.

The present assessment of partially-paralysed victims of stroke is complicated by a lack of objective measurement. A tracking task of the type widely used to measure the performance of skilled operators in a manual control taks is used here to encourage controlled movement in the semiparalysed arm. Quantitative measures derived from such tests provide sensitive indication of trends in performance during rehabilitation, which cannot be detected by routine clinical examination.SommaireÀ présent, le domaine de l’évaluation des victimes partiellement paralysées par les attaques, est compliqué, faute de mesurage objectif. Ici, on se sert d’une ‘tâche de piste’, du type beaucoup utilisé pour mesurer la performance d’opérateurs spécialisés, qui font une tâche de contrôle manuelle pour encourager le mouvement contrôlé dans le bras demi-paralysé. Des mesures quantitatives obtenus par de telles épreuves, donnent une indication sensible des tendances de performance pendant la rééducation, qu’on ne peut pas détecter a l’examen clinique courant.

BOOK REVIEWS: Spinal Cord Dysfunction Vol II Intervention and Treatment.

The role of 5-Hydroxytryptamine (5HT, Serotonin) in biochemistry, physiology, pharmacology and its involvement in migraine are discussed in this book. It is a collection of papers given at a meeting in Copenhagen in 1991 on 5-Hydroxytryptamine mechanisms in primary headaches and it gives the views of many experts in the field. It is the second in a proposed series of books entitled Frontiers in Headache research. The book starts with a review of the historical aspects of 5HT and goes on to give a classification. According to Professor Saxena there are four main receptor types 5HT-1 like, 5HT-2, 5HT-3 and 5HT-4with several subtypes. Dr Humphrey in a later chapter considers that there are three main groups, 5HT-1, 5HT-2 and 5HT-3. He discusses whether 5HT-4 should be classified with 5HT-1 receptors. There still seems some doubt about the classification and Dr Humphrey goes on to say that clarification will undoubtedly come from a comprehensive study of drug action, molecular biology and transduction mechanisms. The last two parts discuss the involvement of 5HT in migraine and sumatriptan in the treatment of acute migraine attacks. In the discussion summary Professor Welch expressed the view that there may be a good chance of dihydroergotamine competing with sumatriptan for effectiveness and that there was a need for a comparative trial of dihydroergotamine and subcutaneous sumatriptan. This is a book containing the views of experts on 5HT and consists of a number of short papers some of which present opposing views as would be expected in a scientific meeting. It does not give a clear picture of the present position and is therefore a book for the expert rather than for the general reader. MARCIA WILKINSON