Susana Rodriguez

The visual amplification of goal-oriented movements counteracts acquired non-use in hemiparetic stroke patients

BackgroundStroke-induced impairments result from both primary and secondary causes, i.e. damage to the brain and the acquired non-use of the impaired limbs. Indeed, stroke patients often under-utilize their paretic limb despite sufficient residual motor function. We hypothesize that acquired non-use can be overcome by reinforcement-based training strategies.MethodsHemiparetic stroke patients (n = 20, 11 males, 9 right-sided hemiparesis) were asked to reach targets appearing in either the real world or in a virtual environment. Sessions were divided into 3 phases: baseline, intervention and washout. During the intervention the movement of the virtual representation of the patients’ paretic limb was amplified towards the target.ResultsWe found that the probability of using the paretic limb during washout was significantly higher in comparison to baseline. Patients showed generalization of these results by displaying a more substantial workspace in real world task. These gains correlated with changes in effector selection patterns.ConclusionsThe amplification of the movement of the paretic limb in a virtual environment promotes the use of the paretic limb in stroke patients. Our findings indicate that reinforcement-based therapies may be an effective approach for counteracting learned non-use and may modulate motor performance in the real world.Stroke-induced impairments result from both primary and secondary causes, i.e. damage to the brain and the acquired non-use of the impaired limbs. Indeed, stroke patients often under-utilize their paretic limb despite sufficient residual motor function. We hypothesize that acquired non-use can be overcome by reinforcement-based training strategies. Hemiparetic stroke patients (n = 20, 11 males, 9 right-sided hemiparesis) were asked to reach targets appearing in either the real world or in a virtual environment. Sessions were divided into 3 phases: baseline, intervention and washout. During the intervention the movement of the virtual representation of the patients’ paretic limb was amplified towards the target. We found that the probability of using the paretic limb during washout was significantly higher in comparison to baseline. Patients showed generalization of these results by displaying a more substantial workspace in real world task. These gains correlated with changes in effector selection patterns. The amplification of the movement of the paretic limb in a virtual environment promotes the use of the paretic limb in stroke patients. Our findings indicate that reinforcement-based therapies may be an effective approach for counteracting learned non-use and may modulate motor performance in the real world.

At Home Motor Rehabilitation in the Chronic Phase of Stroke Using the Rehabilitation Gaming System

In this study, a Virtual Reality system for stroke rehabilitation was left in the homes of chronic stroke patients to monitor the progress of the patients after constant and extended use of the system. The frequency of use indicated that patients were able to use the system independently. We also found an improvement on the Chedoke Arm and Hand Activity Inventory (CAHAI) scale at the end of the treatment.

Plasma Matrix Metalloproteinases in Patients With Stroke During Intensive Rehabilitation Therapy

OBJECTIVE To study plasma levels of matrix metalloproteinases (MMPs) as potential markers of recovery during intensive rehabilitation therapy (IRT) after stroke. DESIGN Prospective and descriptive 3-month follow-up study. SETTING Rehabilitation unit and research center. PARTICIPANTS Patients with first-ever ischemic stroke (n=15) enrolled to IRT (≥3h/d and 5d/wk) and healthy volunteers (n=15) (N=30). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary outcome was to measure plasma MMP3, MMP12, and MMP13 levels and evaluate potential associations with motor/functional scales using a battery of tests (National Institutes of Health Stroke Scale, modified Rankin scale, Barthel Index, Fugl-Meyer Assessment, Functional Ambulation Categories, Medical Research Council scale, Chedoke Arm and Hand Activity Inventory, and the 10-m walk test) before IRT and at 1- and 3-month follow-ups. The secondary outcome was to evaluate the use of these MMPs as biomarkers as predictors of patients outcome. RESULTS MMP levels remained stable during the study period and were similar to those in the healthy volunteer group. However, baseline MMP12 and MMP13 levels were strongly associated with stroke severity and were found to be elevated in those patients with the poorest outcomes. Interestingly, plasma MMP3 was independent of baseline stroke characteristics but was found to be increased in patients with better motor/functional recovery and in patients with larger improvements during rehabilitation. CONCLUSIONS MMPs might act as biologic markers of recovery during rehabilitation therapy related to their roles in both injury and tissue remodeling. Future confirmatory investigations in multicenter studies are warranted by our data.

Patients with spina bifida and bladder cancer. Our experience

Results We found four patients with a mean age of 32.75 years old, one man and three women. Any patient had undergone bladder augmentation. Three patients used as mode of bladder management intermittent catheterization or permanent urethral catheter, and the male had used collector and had been diagnosed of repetitive bladder calculi. Abdominal pain was the first presenting symptom in two patients, hematuria in another one and the last one was diagnosed because of an ureteral obstruction. All of them had previous history of recurrent urinary tract infections. 75% patients had locally advanced stage (T3 or greater) or lymph node metastases at the time of diagnosis. Two patients had died at the time of the study. Conclusions Bladder cancer should be considered on in this patient population, even in young adult women. Therefore a complete screening would be beneficial for earlier detection and improved outcomes in every spina bifida patient with hematuria or chronic infection.

Functional results in young adults with spina bifida. A comparative study among two therapeutic periods

Background At least 75–85% of children born with Spina Bifida (SB) are expected to reach their early adult years. The growing adult SB population encounters a variety of complications including neurological, neurosurgical, cognitive, psychosocial, renal/urological, bowel management, mobility, musculoskeletal/orthopedic, sexual function, skin, and others. Materials and methods We compared two cohorts of adult patients with the diagnosis of Myelomeningocele, Meningocele, and Sacral anomalies associated with Meningocele, regularly controlled in our multidisciplinary SB Unit and treated in two different therapeutical periods. The first series included patients born before 1974 whereas the patients in the second series were born between 1982 and 1989. We collected the data from the medical history, radiographic records and also performed an interview with each patient included in this study. We collected information concerning two aspects: medical and social variables. The medical data included diagnosis, functional neurological level, shunted hydrocephalus, vertebral malformations, intelligence quotient (IQ), urological and faecal incontinence, reeducation of incontinence, orthosis and type of gait. The social data included level of education, employment, marital status and driving licence. We developed a questionnaire with 15 secondary conditions associated with SB which had to be filled in order of importance by all patients with normal or borderline IQ as per Wechsler Scale. Results A total of 206 patients were included in this study: 104 patients in the first series and 102 in the second one. Both series were homogeneous in relation to gender, functional neurological level and diagnosis. We found differences statistically significant in both series in relation to shunted hydrocephalus (p=0.001), spinal deformity (p=0.043), urinary re-education and collection method (p= 0.000), faecal re-education method (p=0.000), gait orthosis (p= 0.045), and educational level (p=0.000) reflecting an improvement in the second series. We found no differences in both series in relation to IQ, incontinence, ambulation, work incorporation, marital status and driving license. Regarding the personal questionnaire, there were statistically significant differences in the perception of both samples in relation to pressure ulcers (p=0.022), urinary incontinence (p=0.001), faecal incontinence (p=0.014), urinary infection (p=0.019), IQ (p=0.012), and sexual activity (p=0.000). Conclusions Management of the musculoskeletal, bowel, bladder, renal, neurological systems, and other issues in SB patients have changed and improved in the last years, regarding not only diagnostic and therapeutic procedures but also a coordinated interdisciplinary team approach that has lead these patients to reach adulthood in better conditions.

Current situation of young adults in a multidisciplinary spina bifida unit

Results A total of 100 patients were included in this study: 57 male and 43 female. The mean age was 21.3 (± 2.3, range 18–25) years. Myelomeningocele represented 91% of the sample. Regarding functional neurological level, 70% of patients belonged to lumbar (medium and low) or sacral. Hydrocephalus was present in 92% of them and 65% required the placement of a shunt. A total of 48% of the sample had a normal IQ. The 59% of the cases had some type of spinal deformity. 57 patients reached community ambulation whereas 24 were wheelchair-dependent. All patients except one case of meningocele were urine incontinent. Faecal and urinary re-education was achieved in 77.5% and 75.3% of our patients respectively. On the social aspect, the majority of our patients were single, had no children, were living with their parents and had a low educational level and work incorporation.

Importance of Angiogenin and Endothelial Progenitor Cells After Rehabilitation Both in Ischemic Stroke Patients and in a Mouse Model of Cerebral Ischemia

Background: Rehabilitation therapy is the only available treatment for stroke survivors presenting neurological deficits; however, the underlying molecules and mechanisms associated with functional/motor improvement during rehabilitation are poorly understood. Objective: Our aim is to study the modulation of angiogenin and endothelial progenitor cells (EPCs) as repair-associated factors in a cohort of stroke patients and mouse models of rehabilitation after cerebral ischemia. Methods: The clinical study included 18 ischemic strokes admitted to an intensive rehabilitation therapy (IRT) unit, 18 non-ischemic controls and brain samples from three deceased patients. Angiogenin and EPCs were measured in blood obtained before and up to 6 months after IRT together with an extensive evaluation of the motor/functional status. In parallel, C57BL/6 mice underwent middle cerebral artery occlusion, and the pasta matrix reaching-task or treadmill exercises were used as rehabilitation models. Angiogenin RNA expression was measured after 2 or 12 days of treatment together with cell counts from EPCs cultures. Results: Brain angiogenin was identified in both human and mouse tissue, whereas serum levels increased after 1 month of IRT in association with motor/functional improvement. EPC populations were increased after stroke and remained elevated during follow-up after IRT. The mouse model of rehabilitation by the task-specific pasta matrix exercise increased the number of EPCs at 2 days and increased angiogenin expression after 12 days of rehabilitation. Conclusions: Angiogenin and EPCs are modulated by rehabilitation after cerebral ischemia, suggesting that both angiogenin and EPCs could serve as biomarkers of improvement during rehabilitation or future therapeutic targets.

Poster 226: Comparative Study of the Functional Results in Young Adults With Spina Bifida During Two Therapeutic Periods. A Case Series

Disclosures: R. L. Kriel, Medtronic Inc, Research grants Objective: Using a dog model, assess the safety and tolerance of intravenous (IV) baclofen. Design: Prospective, crossover, non-blinded after approval from IACUC. Setting: University veterinary science laboratory. Participants: 6 adult hound-mix dogs, 19-25 kg. Interventions: The first 2 dogs received an oral baclofen dose of 10 mg. After a 1-day washout, the same dogs received a 10-mg dose as an IV bolus (2 mg/mL concentration) over 5 minutes. The oral tablet was crushed, suspended in 5 mL of water and administered into the posterior pharynx. The dogs were not sedated. The subsequent 4 dogs were entered into a dose escalation study to determine limits of clinical tolerance and to correlate clinical observation with blood level. The same clinical observation scales were used. Boluses of 0.5, 1.0 and 1.5 mg/kg were given followed by constant infusion of baclofen (rates of 0.1, 0.2 and 0.4 mg/kg/h). Main Outcome Measures: Vital signs, modified Glasgow Coma Scale for Dogs, Discomfort and Behavior Scale. Blood samples were obtained during the observation period for determination of baclofen levels. Results: The boluses of 0.5 mg/kg and 1.0 mg/kg were tolerated with little or no clinical effect, however within 30 minutes of beginning the constant infusion of 0.2 mg/kg/h after the second bolus (1.0 mg/kg) dogs became progressively sedated and ataxic. At the highest dosages, vomiting, profuse salivation, and stupor occurred. At that time infusions were stopped and the dogs were allowed to recover while receiving IV hydration. They recovered to their baseline status within 3-6 hours. Oral bioavailability in the first 2 dogs was 0.66 and 0.69. Half-lives after intravenous administration were 3.32 and 3.58 hours indicating that baclofen was accumulating during infusions. Conclusions: IV baclofen bolus doses of 0.5 and 1.0 mg/kg were tolerated. Definite, but reversible, toxicity occurred at higher plasma baclofen concentrations.

Measuring health outcome in young adults with spina bifida

boyfriend/girlfriend (p=0.017), and not having some of the conditions of the personal questionnaire such as obesity (p=0.008), urinary infections (p=0.004), and scoliosis (p=0.014). A higher score in the HRQL was associated with a better faecal reeducation (p=0.046), gait level (p=0.043), use of gait aids (p=0.017), family economic level (p=0.020), mobility, self-care, and usual activities. A lower score in the HRQL was related to had undergone spine surgery (p=0.016), having anxiety/ depression (p=0.000), and having some of the conditions of the personal questionnaire such us pressure ulcers (p=0.010), and low self-esteem (p=0.024). In the regression model, determinant factors of having worse quality of life measured with EQ VAS were anxiety/depression, obesity, having boyfriend/girlfriend, and urinary infection. Determinant factors of having worse quality of life measured with HRQL were self-care, anxiety/depression, IQ and low self-esteem. Conclusions Almost two thirds of the series referred no problems in the health outcome. The determinants factors related to young SB patients personal perception of quality of life are not those related to disability.

Poster 135: Gait and Balance Analysis Following Spinal Fusion in Adolescent Idiopathic Scoliosis

nal operation scar was made. Other identifiable pathologic processes such as effusion or bursitis were excluded by ultrasound. Points of tenderness were accurately identified along the incision site by applying gentle pressure with a sharpened rubber pencil eraser. Extraarticular nerve block injection (1% lidocaine and 20 mL of Kenalog) was conducted along the incision scar and patient tolerated the procedure well without any complications. Setting: University hospital clinic. Results: 7 days after the procedure the patient was seen in the clinic participating in physical therapy, including active and passive flexion exercises and scar tissue mobilization, with minimum pain. After 2 months the patient completed physical therapy with restored full range of knee flexion and improved ambulation. Discussion: Persistent knee pain after total knee joint arthroplasty may be caused by many factors. Adhesive neuritis due to damage in the infrapatellar branch of saphenous nerve is a common but underrecognized complication. This is a rare case of extension contracture caused by inability to flex the knee presumably due to adhesive neuritis, which seems to be related to multiple revisions of total knee joint arthroplasty. It can be clinically diagnosed by localizing the pain area with a common tool such as sharpened rubber pencil eraser. Physical therapy following nerve block can be an effective option for rehabilitation for this type of condition. Conclusions: Persistent knee pain after total knee joint arthroplasty can have multiple etiologies. In cases of adhesive neuritis, conservative treatment is possible with nerve block injection after precisely localizing the pain.