Ravindra Kumar Garg

Movement therapy induced neural reorganization and motor recovery in stroke: a review.

This paper is a review conducted to provide an overview of accumulated evidence on contemporary rehabilitation methods for stroke survivors. Loss of functional movement is a common consequence of stroke for which a wide range of interventions has been developed. Traditional therapeutic approaches have shown limited results for motor deficits as well as lack evidence for their effectiveness. Stroke rehabilitation is now based on the evidence of neuroplasticity, which is responsible for recovery following stroke. The neuroplastic changes in the structure and function of relevant brain areas are induced primarily by specific rehabilitation methods. The therapeutic method which induces neuroplastic changes, leads to greater motor and functional recovery than traditional methods. Further, the recovery is permanent in nature. During the last decade various novel stroke rehabilitative methods for motor recovery have been developed. This review focuses on the methods that have evidence of associated cortical level reorganization, namely task-specific training, constraint-induced movement therapy, robotic training, mental imaging, and virtual training. All of these methods utilize principles of motor learning. The findings from this review demonstrated convincing evidence both at the neural and functional level in response to such therapies. The main aim of the review was to determine the evidence for these methods and their application into clinical practice.

Meaningful task-specific training (MTST) for stroke rehabilitation: a randomized controlled trial.

Abstract Background/Objective: The upper extremity motor deficit is one of the functional challenges in post stroke patients. The objective of the present study was to evaluate the effectiveness of the meaningful task-specific training (MTST) on the upper extremity motor recovery during the subacute phase after a stroke. Method: This was a randomized, controlled, double-blinded trial in the neurology department of a university hospital and occupational therapy unit of a rehabilitation institute. A convenience sample of 103 people, 4 to 24 weeks (mean, 12.15 weeks) after the stroke, was randomized into 2 groups (MTST, 51; standard training group, 52). Subjects in the Brunnstrom stage of arm recovery of 2 to 5 were included in the study. Ninety-five participants completed the 8-week follow-up. Interventions: Participants were assigned to receive either the MTST or dose-matched standard training program based on the Brunnstrom stage and Bobath neurodevelopmental technique, 4 to 5 days a week for 4 weeks. Fugl-Meyer assessment (FMA), Action Research Arm Test (ARAT), Graded Wolf Motor Function Test (GWMFT), and Motor Activity Log (MAL) were outcome measures Results: The MTST group showed a positive improvement in the mean scores on the outcome measures at post and follow-up assessments in comparison to the control group. Further, statistically significant differences were observed in changes between the groups at post and follow-up assessment for FMA, ARAT, GWMFT, and MAL. Conclusion: The MTST produced statistically significant and clinically relevant improvements in the upper extremity motor recovery of the patients who had a subacute stroke.

Neurological complications of dengue fever: Experience from a tertiary center of north India.

Introduction: Dengue, an acute viral disease transmitted by Aedes mosquitoes, is highly endemic in many tropical and subtropical areas of the world. Neurological complications of dengue infection have been observed more frequently in the recent past and some studies highlighted varied neurological complications arising in the course of dengue illness. In this retrospective study, we report various neurological complications observed during the last 2 years in patients of dengue fever. Materials and Methods: The patients presenting with neurological complications with positive serology (IgM antibody) for dengue infection were consecutively recruited from the Department of Neurology/Medicine from a tertiary center of Lucknow, India. These patients were subjected to a detailed clinical evaluation, laboratory assessment including blood count, hematocrit, coagulation parameters, biochemical assays, serology for dengue fever, enzyme-linked immunosorbent assay for human immunodeficiency virus and other relevant investigations. Results: Twenty-six patients with neurological complications associated with confirmed dengue infection were observed during the last 2 years. Eighteen of these patients were male. Of the 26 patients, 10 patients were suffering from brachial neuritis, four patients had encephalopathy, three patients were consistent with the diagnosis of Guillain Barre syndrome, three patients had hypokalemic paralysis associated with dengue fever and two patients had acute viral myositis. Opsoclonus-myoclonus syndrome was diagnosed in two patients, myelitis in one patient and acute disseminated encephalo-myelitis also in one patient. Conclusion: Dengue fever was associated with widespread neurological complications. Brachial neuritis and opsoclonus-myoclonus syndrome were observed for the first time in this study.

Estimating the Minimal Clinically Important Difference of an Upper Extremity Recovery Measure in Subacute Stroke Patients

Abstract Background: The minimal clinically important difference (MCID) estimates of some of the stroke-related measures are available; but MCID of the Fugl-Meyer assessment (FMA) measure is unknown, which limits the application and interpretation of change scores in poststroke patients with motor deficits. Objective: To estimate the MCID of the FMA-UE (upper extremity) using the modified Rankin scale (mRS) and global rating of patient-perceived changes (GRPPC) in subacute poststroke patients. Methods: The prospective, cohort study took place in the neurology department of a university hospital. Seventy-one subacute poststroke (mean duration, 8.42 weeks) patients were prospectively enrolled in a randomized clinical trial of the ongoing Meaningful Task Specific Training (MTST). FMA-UE, mRS, and GRPPC scores were obtained at pre- and 4 weeks postintervention. Results: The MCID values of FMA-UE were 9 (80.39% sensitive and 70% specific) and 10 (97.62% sensitive and 89.66% specific) anchored to mRS and GRPPC, respectively. Conclusions: The estimated MCID score for the upper extremity motor recovery among patients with subacute stroke is 9 to 10 on the FMA-UE. Patients with subacute stroke who achieve a score of 9 to 10 on FMA-UE are more likely to experience or perceive a meaningful and clinically important improvement in their disability level than those who do not. The reference value can be used to develop goals and interpret progress in subacute poststroke patients.

Short Course of Prednisolone in Indian Patients with Solitary Cysticercus Granuloma and New‐onset Seizures

Summary:  Purpose: To evaluate the role of a short course of oral corticosteroids in Indian patients with solitary cysticercus granuloma with seizures.

Task-Oriented Circuit Class Training Program with Motor Imagery for Gait Rehabilitation in Poststroke Patients: A Randomized Controlled Trial

Abstract Background and Objective: The ability to walk is impaired in more than 80% of poststroke patients. The objective of the present study was to evaluate the effectiveness of the task-oriented circuit class training (TOCCT) with motor imagery (MI) on the gait during the subacute phase after a stroke. Method: This was a randomized, controlled, assessor-blinded trial in a neurology department of a university hospital. A convenience sample of 30 people, 4 to 12 weeks (mean, 6.3 weeks) after the stroke was randomized into 2 groups (the TOCCT with MI and standard training group) of 15 people each. Twenty-nine participants completed the 6-week follow-up. Participants were assigned to receive either the TOCCT with MI or dose-matched standard training program based on the Bobath’s neurodevelopmental technique, 7 days a week for 2 weeks, as outpatients or inpatients. Outcome measures were the Functional Ambulation Classification (FAC), the Rivermead Visual Gait Assessment (RVGA), step length asymmetry, walking speed, and 6-minute walk test (6MWT). Results: The TOCCT with MI group showed a positive improvement in the mean/median scores on most of the outcome measures at post and follow-up assessments in comparison to the control group. However, statistically significant differences were observed in changes between the groups at post and follow-up assessment for FAC, RVGA, walking speed, and 6MWT (ANOVA, P = .001 to .049; Mann-Whitney U test, P = .001). Conclusion: Among the patients who had a stroke within the previous 4 to 12 weeks, the TOCCT with MI produced statistically significant and clinically relevant improvements in the gait and the gait-related activities.

Acute dengue virus myositis: A report of seven patients of varying clinical severity including two cases with severe fulminant myositis

BACKGROUND Acute dengue myositis is characterized by fever and myalgia (with or without muscle weakness). METHOD The 7 cases of acute dengue myositis were retrospectively evaluated in the present study. Dengue myositis was diagnosed on the basis of a clinical picture consistent with the infection, elevated creatine phosphokinase, normal CSF, positive serum IgM for dengue virus, and the exclusion of other causes. RESULTS The mean age of patients was 19.4 (range 3-40) years. Majority (5) of the patients were male. In our series 3 of the cases suffered from fulminant myositis. They were characterized by generalized weaknesses which included the respiratory muscles. All the 3 patients had markedly elevated creatine phosphokinase levels (ranging from 16,590 to 117,200 IU/L). Two patients suffering from fulminant myositis required mechanical ventilation. However, they succumbed to their illnesses. The third patient showed signs of improvement. One case had paraparesis and an elevated creatine phosphokinase level. However, a spontaneous complete recovery was observed. The remaining 3 cases had quadriparesis with trunk and neck weaknesses, sparing of respiratory muscles, creatine phosphokinase levels up to 3000 U/L. However, a complete recovery was observed in these patients within 4 weeks. CONCLUSION To conclude, early respiratory involvement, high creatine phosphokinase values, and severe myalgia suggest a severe form of dengue myositis.

Paradoxical reaction in HIV negative tuberculous meningitis

This review focusses on paradoxical reactions occurring during the treatment of tuberculous meningitis (TBM) in human immunodeficiency virus-negative cases. A paradoxical reaction is defined as the worsening of a pre-existing lesion or the appearance of new lesion in a patient whose clinical symptoms initially improved with anti-tuberculosis treatment. A number of different paradoxical reactions have been reported in patients with TBM including expansion of existing cerebral tuberculomas, and appearance of new tuberculomas, hydrocephalus, and optochiasmatic and spinal arachnoiditis. While the exact mechanism of paradoxical reactions is uncertain, an exaggerated immune reaction against Mycobacterium tuberculosis-associated antigens is currently the most accepted theory for tuberculous paradoxical reaction. Corticosteroids are considered to have a beneficial effect in the management of paradoxical reactions. Immuno-modulatory drugs, including tumor necrosis factor-α antagonists, thalidomide and interferon-γ have been used in isolated cases with more severe forms of paradoxical reactions.

Neuroimaging Features and Predictors of Outcome in Eclamptic Encephalopathy: A Prospective Observational Study

Imaging findings in 45 patients with eclampticposterior reversible encephalopathy syndrome were assessed. The most common affected areas were the occipital, parietal, frontal, and temporal lobes. Serum creatinine, uric acid, and lactate dehydrogenase values and presence of moderate or severe PRES were significantly associated with mortality. Eclamptic PRES demonstrated a higher incidence of atypical distributions and cytotoxic edema than previously thought. BACKGROUND AND PURPOSE: Posterior reversible encephalopathy syndrome is associated with eclampsia. We assessed the distribution and nature of typical and atypical cranial MR imaging findings in these patients and their correlation with clinical and laboratory data and predictors of outcome. MATERIALS AND METHODS: Forty-five clinically confirmed cases of eclampsia were included in this prospective observational study. Subjects with hemolysis, elevated liver enzymes, and low platelets syndrome (n = 9) and pre-existing neurologic conditions (1 with cerebral solitary cysticercus granuloma) were excluded. Patients underwent blood investigations and cranial MR imaging. RESULTS: Twenty-seven patients had abnormal while 8 had normal MR imaging findings. Involvement of brain regions was as follows: frontal, 88.89%; temporal, 44.44%; parietal, 100%; occipital, 100%; deep gray matter, 29.63%; cerebellum, 22.22%; brain stem, 14.81%. Cytotoxic edema was present in 33.33% of cases; 66.67% of patients had mild posterior reversible encephalopathy syndrome; 25.92% had moderate posterior reversible encephalopathy syndrome; and 7.41% had severe posterior reversible encephalopathy syndrome. Abnormal neuroimaging findings were significantly associated with altered sensorium; visual disturbances; status epilepticus; and elevated serum creatinine, uric acid, and lactate dehydrogenase (P = .006, P = .018, P = .015, P = .019, P = .003, and P = .001, respectively). Serum creatinine, uric acid, and lactate dehydrogenase values and the presence of moderate or severe posterior reversible encephalopathy syndrome were significantly associated with mortality (P < .001, P < .001, P = .009, and P = .027, respectively). CONCLUSIONS: Neuroimaging in eclampsia demonstrates a higher incidence of atypical distributions and cytotoxic edema than previously thought. Altered sensorium; visual disturbances; status epilepticus; and elevated serum uric acid, lactate dehydrogenase, and creatinine are associated with abnormal neuroimaging findings. Higher serum creatinine, uric acid, and lactate dehydrogenase levels and moderate and severe forms of posterior reversible encephalopathy syndrome are possible predictors of poor outcome.

Vision impairment in tuberculous meningitis: Predictors and prognosis

BACKGROUND Vision impairment is a devastating complication of tuberculous meningitis. In the present study we evaluated the predictors and prognostic significance of vision impairment in tuberculous meningitis. METHODS In this study, 101 adult patients with tuberculous meningitis were evaluated for vision status and physical disability and were followed up for 6 months. Contrast enhanced magnetic resonance imaging (MRI) was performed at baseline and 6 months. RESULT Out of 101 patients, 74 patients had normal vision and 27 patients had low vision or blindness at enrollment. Thirteen patients died during the study period. Out of 88 patients who survived at 6 months, 68 patients had good vision, 11 patients had low vision and 9 patients had blindness. Predictors of vision deterioration were papilledema, cranial nerve palsies, raised cerebrospinal fluid protein (>1g/L), and presence of optochiasmatic arachnoiditis in MRI. Predictors of blindness, at 6 months, were found to be papilledema, vision acuity < or =6/18, cranial nerve palsies, tuberculous meningitis stage II or III, raised cerebrospinal fluid protein (>1g/L), optochiasmatic arachnoiditis, and optochiasmal tuberculoma. At 6 months, 27 patients had death or severe disability. Predictors of death or severe disability at 6 months were vision acuity < or =6/18, cranial nerve deficits, hemiparesis, clinical stage II or III, and presence of infarct in MRI. CONCLUSION Vision impairment occurred in one-fourth of patients with tuberculous meningitis. Principal causes of vision loss were optochiasmatic arachnoiditis and optochiasmal tuberculoma. Impaired vision predicted death or severe disability.