Thomas Vogt

Occurence and Clinical Predictors of Spasticity After Ischemic Stroke

Background and Purpose— There is currently no consensus on (1) the percentage of patients who develop spasticity after ischemic stroke, (2) the relation between spasticity and initial clinical findings after acute stroke, and (3) the impact of spasticity on activities of daily living and health-related quality of life. Methods— In a prospective cohort study, 301 consecutive patients with clinical signs of central paresis due to a first-ever ischemic stroke were examined in the acute stage and 6 months later. At both times, the degree and pattern of paresis and muscle tone, the Barthel Index, and the EQ-5D score, a standardized instrument of health-related quality of life, were evaluated. Spasticity was assessed on the Modified Ashworth Scale and defined as Modified Ashworth Scale >1 in any of the examined joints. Results— Two hundred eleven patients (70.1%) were reassessed after 6 months. Of these, 42.6% (n=90) had developed spasticity. A more severe degree of spasticity (Modified Ashworth Scale ≥3) was observed in 15.6% of all patients. The prevalence of spasticity did not differ between upper and lower limbs, but in the upper limb muscles, higher degrees of spasticity (Modified Ashworth Scale ≥3) were more frequently (18.9%) observed than in the lower limbs (5.5%). Regression analysis used to test the differences between upper and lower limbs showed that patients with more severe paresis in the proximal and distal limb muscles had a higher risk for developing spasticity (P≤0.001). Spasticity of the upper and lower limb was more frequent in patients with hemihypesthesia than in patients without sensory deficits (P≤0.001). Patients with spasticity showed a lower Barthel Index and EQ-5D score compared with the group without spasticity. Conclusions— Spasticity was present in 42.6% of patients with initial central paresis. However, severe spasticity was relatively rare. Predictors for the development of spasticity were a severe degree of paresis and hemihypesthesia at stroke onset.

Numbness in clinical and experimental pain--a cross-sectional study exploring the mechanisms of reduced tactile function.

Abstract Pain patients often report distinct numbness of the painful skin although no structural peripheral or central nerve lesion is obvious. In this cross‐sectional study we assessed the reduction of tactile function and studied underlying mechanisms in patients with chronic pain and in healthy participants exposed to phasic and tonic experimental nociceptive stimulation. Mechanical detection (MDT) and pain thresholds (MPT) were assessed in the painful area and the non‐painful contralateral side in 10 patients with unilateral musculoskeletal pain. Additionally, 10 healthy participants were exposed to nociceptive stimulation applied to the volar forearms (capsaicin; electrical stimulation, twice each). Areas of tactile hypaesthesia and mechanical hyperalgesia were assessed. MDT and MPT were quantified adjacent to the stimulation site. Tactile hypaesthesia in pain patients and in experimental pain (MDT‐z‐scores: −0.66 ± 0.30 and −0.42 ± 0.15, respectively, both p < 0.01) was paralleled by mechanical hyperalgesia (MPT‐z‐scores: +0.51 ± 0.27, p < 0.05; and +0.48 ± 0.10, p < 0.001). However, hypaesthesia and hyperalgesia were not correlated. Although 9 patients reported numbness, only 3 of them were able to delineate circumscript areas of tactile hypaesthesia. In experimental pain, the area of tactile hypaesthesia could be mapped in 31/40 experiments (78%). Irrespective of the mode of nociceptive stimulation (phasic vs. tonic) tactile hypaesthesia and hyperalgesia developed with a similar time course and disappeared within approximately 1 day. Hypaesthesia (numbness) often encountered in clinical pain can be reproduced by experimental nociceptive stimulation. The time course of effects suggests a mechanism involving central plasticity.

Quality of life in Parkinson's disease patients with motor fluctuations and dyskinesias in five European countries

BACKGROUND Little is known about the relationship between specific subtypes of treatment-associated motor complications and different domains of health-related Quality of Life (QoL) in patients with Parkinsons disease (PD). Larger studies that investigate these aspects within a cross-cultural setting are scarce. OBJECTIVE To assess QoL and its association with on-off fluctuations, peak-dose dyskinesias, biphasic dyskinesias, and off-dystonias in PD patients from five European countries. METHODS Data from 817 PD patients were collected cross-sectionally in France, Germany, Italy, Spain, and the UK. QoL was measured with the generic EuroQoL 5-Dimension questionnaire (EQ-5D) and the disease-specific Parkinsons Disease Questionnaire-39 (PDQ-39). Multivariable linear regression analyses were performed to test the associations of motor complication subtypes with QoL. RESULTS Thirty-three percent of the patients (varying from 23% in Italy to 58% in France) suffered from motor complications, either a single subtype or a combination of different subtypes. On-off fluctuations were associated with a 7.1 percentage point decrease in the EQ-5D (p < 0.001) and a 3.6 percentage point deterioration in the PDQ-39 (p = 0.01). Dyskinesias were not seen to affect global QoL scores, but had detrimental effects on the PDQ-39 dimensions activities of daily living, cognitions, stigma, and bodily discomfort. Patients from Spain, Italy, and France had lower global QoL scores in the multivariable analyses than patients from Germany and the UK. CONCLUSION Motor complications, primarily on-off fluctuations, may impact QoL in PD patients. This substantiates the importance of clinical strategies targeting the prevention, delay of onset, and management of motor complications in PD patients.

Evaluation of carpal tunnel syndrome in patients with polyneuropathy

The difference between the median nerve latency to the second lumbrical muscle and the ulnar nerve latency to the second interosseous muscle (L‐I DIFF) was tested in a prospective study to discriminate whether prolonged distal motor latency of the median nerve in patients with polyneuropathy (PNP) reflects an additional carpal tunnel syndrome (CTS). We investigated 92 patients (107 hands) with CTS, 30 patients (34 hands) with PNP, 22 patients (27 hands) with CTS and coexisting PNP (PNP+CTS), and 77 controls (87 hands). L‐I DIFF was significantly prolonged in both the CTS and PNP+CTS patients as compared to PNP patients and controls. It proved to be the most specific test to differentiate between diffuse (PNP) and focal (entrapment) nerve disorder.

Influence of visual cues on gait in Parkinson's disease during treadmill walking at multiple velocities

OBJECTIVE To evaluate the interaction of different treadmill-induced gait velocities and visual cues on the gait performance in Parkinsons disease (PD). BACKGROUND External cuing has been reported to facilitate hypokinetic gait patterns in PD. METHODS 19 PD-patients and 17 controls volunteered for the study. Gait analyses were conducted using dynamic pressure sensors integrated in a treadmill at a given velocity of 1, 2, 3 or 4 km/h. For each velocity, measurements were performed under three conditions. The first condition was without visual cuing, the remaining two consisted of visual cuing e.g. white stripes put on the treadmill belt 25 or 50 cm apart. RESULTS Visual cuing lowered the cadence and increased stride length and stride time while maintaining gait velocity in both PD-patients and controls. A significant interaction between this effect of visual cuing and gait velocity was observed. Visual cuing demonstrated a clear velocity-dependency with less influence on cadence, stride length, stride time and coefficient of variation in stride time at higher velocities. At lower velocities visual cuing was more effective in reducing gait variability as assessed by the coefficient of variation in stride time in PD-patients than in controls. CONCLUSION The current experiment shows that the gait patterns of PD-patients are not rigidly coupled to gait velocity and can be manipulated with visual cuing techniques. Our results suggest that visual cuing can improve the efficacy of treadmill training. Due to an interaction between the effect of visual cuing and gait velocity, the application of visual cues could enhance the efficacy of treadmill training particularly at lower velocities.

Eosinophilic Meningitis due to Angiostrongylus cantonensis in Germany

We report a case of eosinophilic meningitis due to Angiostrongylus cantonensis in a patient who returned from Thailand. The presence of a compatible epidemiologic history and eosinophilia in cerebrospinal fluid (CSF) lead to the diagnosis, which was confirmed by detection of specific antibodies. After treatment with albendazole and corticosteroids he recovered completely.

Pain in chemotherapy-induced neuropathy – More than neuropathic?

Summary In chemotherapy‐induced neuropathy, different pain patterns might help to identify subgroups with predominant neuropathic or musculoskeletal pain and thereby allow a more specific treatment. Abstract Chemotherapy‐induced neuropathy (CIN) is an adverse effect of chemotherapy. Pain in CIN might comprise neuropathic and nonneuropathic (ie, musculoskeletal) pain components, which might be characterized by pain patterns, electrophysiology, and somatosensory profiling. Included were 146 patients (100 female, 46 male; aged 56 ± 0.8 years) with CIN arising from different chemotherapy regimens. Patients were characterized clinically through nerve conduction studies (NCS) and quantitative sensory testing (QST). Questionnaires for pain (McGill) and anxiety/depression (Hospital Anxiety and Depression Scale) were supplied. Patients were followed‐up after 17 days. Large‐ (61%) and mixed‐ (35%) fibre neuropathies were more frequent than small‐fibre neuropathy (1.4%). The 5 major chemotherapeutic regimens impacted differently on large‐ but not on small‐fibre function and did not predict painfulness. Chronic pain associated with CIN was reported in 41.7%. Painless and painful CIN did not differ in QST profiles or electrophysiological findings, but different somatosensory patterns were found in CIN subgroups (pain at rest [RestP], n = 25; movement‐associated pain [MovP], n = 15; both pain characteristics [MovP+RestP], n = 21; or no pain [NonP], n = 85): small‐fibre function (cold‐detection threshold, CDT: z score: −1.46 ± 0.21, P < 0.01) was most impaired in RestP; mechanical hyperalgesia was exclusively found in MovP (z score: +0.81 ± 0.30, P < 0.05). “Anxiety” discriminated between painful and painless CIN; “CDT” and “anxiety” discriminated between patients with ongoing (RestP) and movement‐associated pain (MovP) or pain components (MovP+RestP). The detrimental effect of chemotherapy on large fibres failed to differentiate painful from painless CIN. Patients stratified for musculoskeletal or neuropathic pain, however, differed in psychological and somatosensory parameters. This stratification might allow for the application of a more specific therapy.

Pancuronium improves the neuromuscular transmission defect of human organophosphate intoxication

Two patients with acute severe organophosphate intoxication showed (1) single evoked compound muscle action potentials (CMAP) with repetitive discharges and (2) prominent decremental responses of CMAP with 20 and 50 Hz supramaximal nerve stimulation. Following the intravenous injection of single small doses of pancuronium, marked improvement in these abnormalities occurred and persisted for several hours. We postulate that the physiologic improvement following low-dose pancuronium results from blockade of acetylcholine receptors, especially those 1ocate.d on the terminal axon responsible for antidromic backfiring.

Idiopathic trigeminal sensory neuropathy with gadolinium enhancement in the cisternal segment

Article abstract The authors report two patients with idiopathic trigeminal sensory neuropathy who showed gadolinium enhancement of the cisternal segment of the corresponding trigeminal nerve in cranial MRI. The resolution of these lesions in a repeat MRI suggests a similarity to Bell’s palsy.

Estimation of further disease progression of Parkinson’s disease by dopamin transporter scan vs clinical rating

BACKGROUND Imaging techniques like ß-CIT Scan are valuable diagnostic tools for Parkinsons disease (PD) and correlate in most cases with clinical symptoms. In some patients, however, clinical and imaging data are conflicting. It has not yet been evaluated, which parameter provide more information about severity and disease progression in those patients. AIM To estimate the predictive value of UPDRS and ß-CIT in PD on clinical impairment at follow up. DESIGN AND METHODS In a longitudinal study, 44 PD patients who underwent ß-CIT Scan for diagnostic purpose were followed up for a mean of 44 months. At baseline we assessed UPDRS motor score as well as the subtype of PD, presence of dementia or motor complications. Disease staging at follow up was displayed by UPDRS II (ADL) and III (motor score) as well as by Hoehn & Yahr classification. RESULTS ß-CIT could significantly discriminate PD patients from controls and the tracer uptake ratios (UR) correlated well with UPDRS motor score at baseline. There was, however, only a weak correlation between UR and staging parameters at follow up, whereas UPDRS at baseline was highly correlated with impairment at follow up. CONCLUSION The data suggest a more significant predictive value of UPDRS motor score on disability in the course of disease progression than ß-CIT Scan. Low receptor binding may not be mistaken for a bad prognosis.