Sara Salles

Increase in Sensorimotor Cortex Response to Somatosensory Stimulation Over Subacute Poststroke Period Correlates With Motor Recovery in Hemiparetic Patients

Background. Somatosensory input to the motor cortex may play a critical role in motor relearning after hemiparetic stroke. Objective. The authors tested the hypothesis that motor recovery after hemiparetic stroke relates to changes in responsiveness of the sensorimotor cortex (SMC) to somatosensory input. Methods. A total of 10 hemiparetic stroke patients underwent serial functional magnetic resonance imaging (fMRI) during tactile stimulation and testing of sensorimotor function over 1 year—at early subacute, late subacute, and chronic poststroke time points. Results. Over the subacute poststroke period, increased responsiveness of the ipsilesional SMC to tactile stimulation of a stroke-affected digit correlated strongly with concurrent gains in motor function. Increased responsiveness of the ipsilesional and contralesional SMC over the subacute period also correlated strongly with motor recovery experienced over the first year poststroke. Conclusions. These findings suggest that increased responsiveness of the SMC to somatosensory stimulation over the subacute poststroke period may contribute to motor recovery.

The long-term impact of physical and emotional trauma: the station nightclub fire.

Background Survivors of physical and emotional trauma experience enduring occupational, psychological and quality of life impairments. Examining survivors from a large fire provides a unique opportunity to distinguish the impact of physical and emotional trauma on long-term outcomes. The objective is to detail the multi-dimensional long-term effects of a large fire on its survivor population and assess differences in outcomes between survivors with and without physical injury. Methods and Findings This is a survey-based cross-sectional study of survivors of The Station fire on February 20, 2003. The relationships between functional outcomes and physical injury were evaluated with multivariate regression models adjusted for pre-injury characteristics and post-injury outcomes. Outcome measures include quality of life (Burn Specific Health Scale–Brief), employment (time off work), post-traumatic stress symptoms (Impact of Event Scale–Revised) and depression symptoms (Beck Depression Inventory). 104 fire survivors completed the survey; 47% experienced a burn injury. There was a 42% to 72% response rate range. Although depression and quality of life were associated with burn injury in univariate analyses (p<0.05), adjusted analyses showed no significant relationship between burn injury and these outcomes (p = 0.91; p = .51). Post-traumatic stress symptoms were not associated with burn injury in the univariate (p = 0.13) or adjusted analyses (p = 0.79). Time off work was the only outcome in which physical injury remained significant in the multivariate analysis (p = 0.03). Conclusions Survivors of this large fire experienced significant life disruption, including occupational, psychological and quality of life sequelae. The findings suggest that quality of life, depression and post-traumatic stress outcomes are related to emotional trauma, not physical injury. However, physical injury is correlated with employment outcomes. The long-term impact of this traumatic event underscores the importance of longitudinal and mental health care for trauma survivors, with attention to those with and without physical injuries.

Non-invasive brain stimulation and robot-assisted gait training after incomplete spinal cord injury: A randomized pilot study

BACKGROUND Locomotor training with a robot-assisted gait orthosis (LT-RGO) and transcranial direct current stimulation (tDCS) are interventions that can significantly enhance motor performance after spinal cord injury (SCI). No studies have investigated whether combining these interventions enhances lower extremity motor function following SCI. OBJECTIVE Determine whether active tDCS paired with LT-RGO improves lower extremity motor function more than a sham condition, in subjects with motor incomplete SCI. METHODS Fifteen adults with SCI received 36 sessions of either active (n = 9) or sham (n = 6) tDCS (20 minutes) preceding LT-RGO (1 hour). Outcome measures included manual muscle testing (MMT; primary outcome measure); 6-Minute Walk Test (6MinWT); 10-Meter Walk Test (10MWT); Timed Up and Go Test (TUG); Berg Balance Scale (BBS); and Spinal Cord Independence Measure-III (SCIM-III). RESULTS MMT showed significant improvements after active tDCS, with the most pronounced improvement in the right lower extremity. 10MWT, 6MinWT, and BBS showed improvement for both groups. TUG and SCIM-III showed improvement only for the sham tDCS group. CONCLUSION Pairing tDCS with LT-RGO can improve lower extremity motor function more than LT-RGO alone. Future research with a larger sample size is recommended to determine longer-term effects on motor function and activities of daily living.

Subcutaneous Botulinum Toxin A for the Treatment of Refractory Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is a chronic neuropathic pain condition of unclear etiology that can be very difficult to treat. Typically, CRPS affects the extremities, although it can affect any area of the body [1]. In 2010, the Budapest criteria for the clinical diagnosis of CRPS were established as an update to the more nonspecific criteria originally given in 1994 [2]. Currently, to meet the diagnosis of CRPS, a patient must present with the following conditions: 1. Continuing pain that is disproportionate to any inciting event. 2. At least one symptom reported in 3 of the 4 following categories: a. Sensory: reports of allodynia and/or hyperesthesia type symptoms. b. Vasomotor: temperature asymmetry and/or skin color changes. c. Sudomotor/edema: edema and/or sweating changes/asymmetry. d. Motor/trophic: decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin). 3. At least one sign at the time of evaluation in 2 or more of the following categories: a. Sensory: hyperalgesia to pinprick and/or allodynia to light touch (or deep somatic pressure or joint movement). b. Vasomotor: temperature asymmetry and/or skin color changes (or asymmetry). c. Sudomotor and/or edema: edema and/or sweating changes (or asymmetry). d. Motor and/or trophic: decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin).

Noninvasive evaluation of electrical stimulation impacts on muscle hemodynamics via integrating diffuse optical spectroscopies with muscle stimulator

Abstract. Technologies currently available for the monitoring of electrical stimulation (ES) in promoting blood circulation and tissue oxygenation are limited. This study integrated a muscle stimulator with a diffuse correlation spectroscopy (DCS) flow-oximeter to noninvasively quantify muscle blood flow and oxygenation responses during ES. Ten healthy subjects were tested using the integrated system. The muscle stimulator delivered biphasic electrical current to right leg quadriceps muscle, and a custom-made DCS flow-oximeter was used for simultaneous measurements of muscle blood flow and oxygenation in both legs. To minimize motion artifact of muscle fibers during ES, a novel gating algorithm was developed for data acquisition at the time when the muscle was relaxed. ES at 2, 10, and 50 Hz were applied for 20 min on each subject in three days sequentially. Results demonstrate that the 20-min ES at all frequencies promoted muscle blood flow significantly. However, only the ES at 10 Hz resulted in significant and persistent increases in oxy-hemoglobin concentration during and post ES. This pilot study supports the application of the integrated system to quantify tissue hemodynamic improvements for the optimization of ES treatment in patients suffering from diseases caused by poor blood circulation and low tissue oxygenation (e.g., pressure ulcer).

Trialing of intrathecal baclofen therapy for refractory stiff-person syndrome.

Objective Stiff-person syndrome (SPS) is a rare disorder of the central nervous system characterized by stiffness and muscle spasms that may be progressive in nature. When oral medication is inadequate to control muscle spasticity, intrathecal baclofen may be used. We report a patient with severe SPS and glutamate decarboxylase negative [GAD(−)] (note: GAD(−) indicates the patient has no antibodies to GAD), refractory to oral standard therapies. The patient was effectively trialed with an intrathecal catheter and subsequently treated with chronic intrathecal baclofen, which provided significant relief of spasticity symptoms. Case Report A 48-year-old white man with a history consistent with SPS presented to the clinic. His previous history showed that he met several diagnostic criteria for GAD(−) SPS and had a muscle biopsy positive for myositis. Oral medications were unable to control his muscle spasticity, preventing him from working. The patient received an intrathecal trial using a lumbar approach for placement of a thoracic catheter with an initial baclofen dose of 50 &mgr;g/d. Gradual titration to symptom relief was performed up to 150 &mgr;g/d. Functional evaluation by our physical therapist showed improved motor function, the temporary catheter was removed, and a permanent intrathecal pump placed for intrathecal baclofen infusion. The patient reported excellent symptom relief over the next 6 months and improved activity. Conclusions Refractory SPS is difficult to treat and has few therapeutic options. We report a GAD(−) patient with SPS and resulting debilitating spasticity that was refractory to oral medications who underwent successful continuous intrathecal catheter trial of baclofen over 4 days and subsequently went on to implantation of intrathecal pump. The literature reports only 5 cases of GAD(−) SPS patients treated with intrathecal baclofen therapy, and these resulted in poor long-term success. Our patient completed a 4-day trial of intrathecal baclofen titrated to effect before pump implantation. We advocate continuous intrathecal trialing, as opposed to single-injection technique, to possibly better determine the effective therapeutic dose and ensure posttrialing successful therapy.

Neuroleptic Malignant Syndrome Associated With the Use of Carbidopa/Levodopa for Dystonia in Persons With Cerebral Palsy

Cerebral palsy (CP) is a disorder of movement and posture resulting from a nonprogressive injury to the immature brain that is marked by changes in muscle tone at rest and with activity [1]. The diagnosis is usually made during childhood. Affected children have delayed motor development that usually is substantiated by magnetic resonance imaging findings [1]. Hypotonia may be present in the early stages of CP, but upper motor neuron findings ultimately predominate, with increased tone and hyperreflexia and impaired motor control, balance, and coordination. These changes often lead to secondary contractures and deformities. Various movement disorders are found in patients with CP, including spasticity, dystonia, choreoathetosis, and ataxia. Dystonia is usually treated medically with agents that stimulate dopaminergic activity. The combination drug consisting of levodopa and carbidopa uses levodopa as a precursor to dopamine that is able to cross the blood-brain barrier for conversion to dopamine in the central nervous system [2]. Trihexyphenidyl and benztropine are anticholinergic medications used to treat dystonia by antagonizing remaining cholinergic receptors. All these medications are used to re-establish a balance between injured dopamine and acetylcholine pathways, which are hypothesized to coexist in the substantia nigra of the basal ganglia [3]. Neuroleptic malignant syndrome (NMS), a disorder thought to be caused by dopamine receptor blockade, causes fever, rigidity, and altered mental status [4,5]. Normally this disorder is caused by antipsychotic medications or abrupt withdrawal of dopamine agonists [6].

Botulinum toxin a injection to facial and cervical paraspinal muscles in a patient with stiff person syndrome: a case report.

Stiff person syndrome (SPS) is a rare neurologic disorder of unknown etiology characterized by increased resting muscle tone, progressive rigidity, and stiffness of the axial musculature. We present a case of a 48‐year‐old male patient with SPS who experienced facial and neck muscle spasms that were uncontrolled with oral medications and the use of an intrathecal baclofen pump. Botulinum toxin A injections into the bilateral masseter and neck paraspinal muscles provided pain relief and spasm control, illustrating the use of botulinum toxin A injections in the small muscles of face and neck in patients with SPS.

Arnold-Chiari 1 malformation type 1 with syringohydromyelia presenting as acute tetraparesis: A case report

Abstract Context A 19-year-old woman who presented to a community hospital after awakening with tetraparesis, generalized paresthesia, and severe neck pain, and was transferred to an acute care hospital. Findings Magnetic resonance imaging of the head and spine was performed and revealed a cystic lesion extending from the C1 level to the C6 level as well as an Arnold-Chiari type 1 malformation. Emergent surgical posterior fossa decompression with duraplasty and C1 laminectomy was undertaken. Most symptoms improved immediately postoperatively. On post-operative day 15, the patient was transferred to our acute rehabilitation hospital for an additional 16 days. With continued aggressive therapy, she demonstrated complete resolution of tetraparesis as well as significant improvement in muscle strength and function in addition to resolution of paresthesia and neck pain. Functional independence measure scores were 69/126 on admission to 110/126 on discharge from the rehabilitation hospital. Her tetraparesis eventually resolved; manual muscle testing scores on follow-up 2 months later were 5/5 in all four extremities. Clinical relevance This is the first reported case of Chiari I malformation with syringohydromyelia presenting as acute tetraparesis, generalized paresthesia, and neck pain. Surgical decompression leading to resolution of symptoms made other etiologies extremely unlikely and there was no history of trauma. The different theories on the pathogenesis of syringomyelia are discussed.

Opioid Use in Chronic Pain Patients with Chronic Kidney Disease: A Systematic Review

Objectives To investigate the prevalence of chronic pain and opioid management among patients with chronic kidney disease (CKD). Design Systematic review. Methods A systematic search was performed, including citations from 1960 to May 2015. The review highlights methodological quality assessment of the selected studies; prevalence of pain; type, dose, and reason for opioid use; effectiveness of pain control and associated adverse effects of opioids in CKD patients. Results Twelve of 131 articles met inclusion criteria. There were no randomized controlled trials (RCT) evaluable, and 12 were observational studies. Out of 12 studies, four were of high quality, six were of moderate quality, and the remaining two were low-quality studies. The studies were from different countries with sample size ranging from 10 to 12,782. Several studies showed a high prevalence of chronic uncontrolled pain. The effectiveness of different categories of opioids, dose, duration, and commonly prescribed opioids varied across studies. Conclusions Based on a systematic review of the current literature, there is fair evidence for the high prevalence of chronic pain among patients with CKD, which is not being effectively managed, probably due to underprescription of analgesics or opioids in the CKD population. Clinicians are in need of additional and well-designed randomized control trials that focus on the indications for opioid therapy, appropriate opioid doses and dosing intervals, outcomes with adequacy of symptom control, and reporting on the incidence of adverse side effects.