W. De Weerdt

Effect of pelvic-floor re-education on duration and degree of incontinence after radical prostatectomy: a randomised controlled trial.

BACKGROUND Urinary incontinence is a common long-term complication after radical prostatectomy. Spontaneous recovery of normal urinary control after surgery can take 1-2 years. We aimed to investigate whether there was any beneficial effect of pelvic-floor re-education for patients with urinary incontinence as a result of radical prostatectomy. METHODS 102 consecutive incontinent patients who had had radical retropubic prostatectomy for clinically localised prostate cancer and who could comply with the ambulatory treatment schedule in our hospital were randomised, after catheter removal, into a treatment group (n=50) and a control group (n=52). Patients in the treatment group took part in a pelvic-floor re-education programme for as long as they were incontinent, and for a maximum of 1 year. The control group received placebo therapy. The primary endpoint was continence rate at 3 months. Incontinence was assessed objectively with the 1 h and 24 h pad tests and subjectively by the visual analogue scale. The groups were analysed on an intention-to-treat basis by ANOVA and chi2-test. FINDINGS In the treatment group continence was achieved after 3 months in 43 (88%) of 48 patients. In the control group, continence returned after 3 months in 29 (56%) of 52 patients. At 1 year, the difference in proportion between treatment and control group was 14% (95% CI 2-27). In the treatment group improvement in both duration (log-rank test, p=0.0001) and degree of incontinence (Wald test, p=0.0010) was significantly better than in the control group. INTERPRETATION Pelvic-floor re-education should be considered as a first-line option in curing incontinence after radical prostatectomy.

The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke

Objective: To examine the clinimetric characteristics of the Trunk Impairment Scale (TIS). This newly developed scale evaluates motor impairment of the trunk after stroke. The TIS scores, on a range from 0 to 23, static and dynamic sitting balance as well as trunk co-ordination. It also aims to score the quality of trunk movement and to be a guide for treatment. Design: Two physiotherapists observed each patient simultaneously, but scored independently. Each patient was re-examined by one of the therapists. Subjects: Twenty-eight patients in a rehabilitation setting. Results: Kappa and weighted kappa values for item per item reliability ranged for all but two, from 0.62 to 1. All percentages of agreement exceeded 81%. Intraclass correlations (ICC) for the summed scores of the different subscales were between 0.85 and 0.99. Test–retest and interobserver reliability for the TIS total score (ICC) was 0.96 and 0.99, respectively. The 95% limits of agreement for the test–retest and interexaminer measurement error were -2.90, 3.68 and -1.84, 1.84, respectively. Cronbach alpha coefficients for internal consistency ranged from 0.65 to 0.89. Content validity was defined. Spearman rank correlations with the Barthel Index (r5=0.86) and the Trunk Control Test (r5=0.83) was used to examine construct and concurrent validity, respectively. Conclusions: Analysis of different clinimetric parameters support the use of the TIS in both clinical use and future stroke research. Guidelines for treatment and level of quality of trunk activity can be derived from the assessment.

The European Stroke Scale.

For detecting therapeutic effect and matching of treatment groups in stroke trials, a scale that meets the clinimetric criteria is of the utmost importance. Methods The European Stroke Scale consists of 14 items selected for their specificity and their prognostic value. It is designed for patients with middle cerebral artery stroke. Interrater reliability, internal consistency, and time for completion were investigated in 74 patients. Intrarater reliability was studied in 38 patients. To establish concurrent validity, two trials were performed in 20 and 44 patients. The scale was correlated with the MCA Neurological Scale, the Canadian Stroke Scale, the Scandinavian Stroke Scale, the Barthel Index, and the Rankin Scale. Correlations were calculated by means of Spearmans correlation coefficient. The trial in 44 patients also investigated the prognostic validity of the scale for 1-month and 8-month neurological, functional, and handicap status. These data were analyzed by linear regression. Results Interrater (K value range, 0.62 to 0.85) and intrarater (K value range, 0.65 to 1.00) reliability for each item was good, and internal consistency was excellent (Cronbachs α coefficient, 0.92). Mean time for completion was 8.2 minutes (range, 4 to 14 minutes). Correlations of the European Stroke Scale with other neurological scales ranged from 0.93 to 0.95. The correlation with the Barthel Index and the Rankin Scale was 0.84 and −0.86. The R2 values for prognostic validity ranged from 0.45 to 0.81 (P≤.0001). Conclusions The European Stroke Scale has been developed according to the clinimetric criteria.

Effect of simulator training on driving after stroke : A randomized controlled trial

Background: Neurologically impaired persons seem to benefit from driving-training programs, but there is no convincing evidence to support this notion. The authors therefore investigated the effect of simulator-based training on driving after stroke. Methods: Eighty-three first-ever subacute stroke patients entered a 5-week 15-hour training program in which they were randomly allocated to either an experimental (simulator-based training) or control (driving-related cognitive tasks) group. Performance in off-road evaluations and an on-road test were used to assess the driving ability of subjects pre- and post-training. Outcome of an official predriving assessment administered 6 to 9 months poststroke was also considered. Results: Both groups significantly improved in a visual and many neuropsychological evaluations and in the on-road test after training. There were no significant differences between both groups in improvements from pre- to post-training except in the “road sign recognition test” in which the experimental subjects improved more. Significant improvements in the three-class decision (“fit to drive,” “temporarily unfit to drive,” and “unfit to drive”) were found in favor of the experimental group post-training. Academic qualification and overall disability together determined subjects that benefited most from the simulator-based driving training. Significantly more experimental subjects (73%) than control subjects (42%) passed the follow-up official predriving assessment and were legally allowed to resume driving. Conclusions: Simulator-based driving training improved driving ability, especially for well educated and less disabled stroke patients. However, the findings of the study may have been modified as a result of the large number of dropouts and the possibility of some neurologic recovery unrelated to training.

Predictors of fitness to drive in people with Parkinson disease

Objective: To develop an efficient clinical screening battery to accurately predict the fitness to drive in people with Parkinson disease (PD). Methods: This prospective study included 80 participants: 40 patients with PD and 40 healthy age- and sex-matched control subjects. All participants were assessed using a driving simulator, a driving history survey, and the Clinical Dementia Rating. The patients with PD also underwent a clinical test battery and an evaluation of fitness to drive performed by an official center, which included visual, cognitive, and on-road tests. A two-class decision from this driving assessment center was the main outcome measure. Results: A screening battery assessing four clinical variables (disease duration, contrast sensitivity, Clinical Dementia Rating, and motor part of the Unified Parkinson’s Disease Rating Scale) provided the best model (R2 = 0.52) to predict the fitness to drive and correctly classified 36 (90%) of the patients with PD as pass or fail (sensitivity = 91%, specificity = 90%). The Test Ride for Investigating Practical fitness to drive (TRIP) driving simulator score discriminated significantly between drivers with PD and their healthy peers (p = 0.0008). When the TRIP driving simulator score was added to the clinical model, the total explained variance increased (R2 = 0.60) and correctly classified 39 (97.5%) of drivers with PD into the pass/fail category (sensitivity = 91%, specificity = 100%). Conclusions: A short clinical screening battery that measures disease duration, contrast sensitivity, cognitive and motor functions can predict fitness to drive in people with Parkinson disease with a high degree of accuracy. GLOSSARY: ADL = activities of daily living; CDR = Clinical Dementia Rating; CS = contrast sensitivity; DBS = deep brain stimulator; ESS = Epworth Sleepiness Scale; IQR = interquartile range (Q1–Q3); NA = not applicable; PD = Parkinson disease; rb = biserial correlation coefficient; rrb = rank biserial correlation coefficient; rs = Spearman rank correlation coefficient; TRIP = Test Ride for Investigating Practical fitness to drive; UFOV = useful field of view; UPDRS II = Unified Parkinson’s Disease Rating Scale, activities of daily living; UPDRS III = Unified Parkinson’s Disease Rating Scale, motor scale; w = Wilcoxon rank sum test.

Interlimb coordination in patients with Parkinson's disease: motor learning deficits and the importance of augmented information feedback

Abstract The basal ganglia have traditionally been associated with motor control functions and this view has prevailed since the late nineteenth century. Recent experimental studies suggest that this neuroanatomical system is also critically involved in motor learning. In the present study, motor learning/transfer capabilities were compared between patients with Parkinson’s disease and a group of normal elderly people. Subjects practiced a bimanual coordination task that required continuous flexion-extension movements in the transverse plane with a 90° phase offset between the forearms. During acquisition, augmented visual feedback of the relative motions was provided in real time. The findings revealed improvements in the bimanual coordination pattern across practice in both groups when the augmented concurrent feedback was present. However, when transferred to performance conditions in which the augmented information was withheld, performance deteriorated (relative to the augmented condition) and this effect was more prevalent in the Parkinson patients. More specifically, no improvement in interlimb coordination was observed under nonaugmented feedback conditions across practice. Instead, a drift toward the preferred in-phase and anti-phase coordination patterns was evident. The present findings suggest that Parkinson patients can improve their performance on a new motor task, but they remain strongly dependent on augmented visual information to guide these newly acquired movements. The apparent adoption of a closed-loop control mode is accompanied with decreases in movement speed in order to use the feedback to ensure accuracy. When the augmented feedback is withheld and the movement pattern is to be controlled by means of intrinsic information feedback sources, performance is severely hampered. The findings are hypothesized to indicate that learning/transfer is affected in Parkinson patients who apparently prefer some constancy in the environmental contingencies under which practice takes place. The present findings are consistent with the notion that the basal ganglia form a critical neuroanatomical substrate for motor learning.

The effect of a home physiotherapy program for persons with Parkinson's disease

The purpose of this study was to evaluate the effect of a home physiotherapy program for persons with Parkinsons disease. Thirty-three patients took part in the study using a within-subject controlled design. Functional activities including walking and carrying out transfers were measured at home and in the hospital before and after a 6-week baseline period, after 6 weeks home physiotherapy and after 3 months follow-up. Spatiotemporal and plantar force variables of gait were determined with video and pododynography. Treatment provided by community physiotherapists consisted of teaching cueing and conscious movement control 3 times a week. The study revealed that patients had significantly higher scores on a functional activity scale after treatment in the home setting and to a lesser degree in hospital, a result, which was partly sustained at follow-up. However, duration of the transfer movements, spatiotemporal and plantar force variables were not significantly improved except for stride length. The results support application and development of the treatment concept and highlight that physiotherapy aimed at improving function in Parkinsons disease is best provided in the home situation.

Screening for fitness to drive after stroke: A systematic review and meta-analysis

Objective: To identify the best determinants of fitness to drive after stroke, following a systematic review and meta-analysis. Methods: Twenty databases were searched, from inception until May 1, 2010. Potentially relevant studies were reviewed by 2 authors for eligibility. Methodologic quality was assessed by Newcastle-Ottawa scores. The fitness-to-drive outcome was a pass–fail decision following an on-road evaluation. Differences in off-road performance between the pass and fail groups were calculated using weighted mean effect sizes (dw). Statistical heterogeneity was determined with the I2 statistic. Random-effects models were performed when the assumption of homogeneity was not met. Cutoff scores of accurate determinants were estimated via receiver operating characteristic analyses. Results: Thirty studies were included in the systematic review and 27 in the meta-analysis. Out of 1,728 participants, 938 (54%) passed the on-road evaluation. The best determinants were Road Sign Recognition (dw 1.22; 95% confidence interval [CI] 1.01–1.44; I2, 58%), Compass (dw 1.06; 95% CI 0.74–1.39; I2, 36%), and Trail Making Test B (TMT B; dw 0.81; 95% CI 0.48–1.15; I2, 49%). Cutoff values of 8.5 points for Road Sign Recognition, 25 points for Compass, and 90 seconds for TMT B were identified to classify unsafe drivers with accuracies of 84%, 85%, and 80%, respectively. Three out of 4 studies found no increased risk of accident involvement in persons cleared to resume driving after stroke. Conclusions: The Road Sign Recognition, Compass, and TMT B are clinically administrable office-based tests that can be used to identify persons with stroke at risk of failing an on-road assessment.

Prediction of Driving After Stroke: A Prospective Study

The process of determining whether patients with stroke should drive again often involves off-road evaluations and road tests that usually take about 2 to 3 h to complete. Objectives. This prospective study sought to identify the combination of tests that best predicts fitness to drive after stroke. The main aim was to develop a short and predictive predriving assessment battery. Methods. Sixty-eight consecutive stroke patients were studied who performed a mandatory predriving assessment at the Belgian Road Safety Institute, Brussels, within 18 months. Performance in a predriving assessment included medical examination (when needed), visual and neuropsychological evaluations, and an on-road test. Based on these assessments, a physician, psychologist, and the driving safety expert who administered the tests decided if a subject was either “fit to drive,”“temporarily unfit to drive,” or “unfit to drive.” Results. Logistic regression analysis revealed a combination of visual neglect, figure of Rey, and on-road tests as the model that best predicted (R 2 = 0.73) fitness to drive after stroke. Using a discriminant function that included the 3 tests of the logistic model, the fitness to drive judgments of 59 (86.8%) subjects were correctly predicted. The sensitivity and specificity of the predictions were 79.4% and 94.1%, respectively. Conclusion. Fitness to drive after stroke can be predicted from performance on a few road-related tests with a high degree of accuracy. However, some individuals require extended assessments and further tests.

Comprehensive assessment of gesture production: a new test of upper limb apraxia (TULIA)

Background:  Only few standardized apraxia scales are available and they do not cover all domains and semantic features of gesture production. Therefore, the objective of the present study was to evaluate the reliability and validity of a newly developed test of upper limb apraxia (TULIA), which is comprehensive and still short to administer.