Wendy S. Shore

A pilot study of functional electrical stimulation cycling in progressive multiple sclerosis.

BACKGROUND Functional electrical stimulation (FES) cycling is used by spinal cord injury patients to facilitate neurologic recovery and may also be useful for progressive MS patients. OBJECTIVE To evaluate the safety and preliminary efficacy of home FES cycling in progressive MS and to explore how it changes cerebrospinal fluid (CSF) cytokine levels. METHODS Five patients with primary or secondary progressive MS were given an FES cycle for six months. Main outcome measures were: Two Minute Walk Test, Timed 25-foot Walk, Timed Up and Go Test, leg strength, Expanded Disability Status Scale (EDSS) score, and Multiple Sclerosis Functional Composite (MSFC) score. Quality-of-life was measured using the Short-Form 36 (SF-36). Cytokines and growth factors were measured in the CSF before and after FES cycling. RESULTS Improvements were seen in the Two Minute Walk Test, Timed 25-foot Walk, and Timed Up and Go tests. Strength improved in muscles stimulated by the FES cycle, but not in other muscles. No change was seen in the EDSS score, but the MSFC score improved. The physical and mental health subscores and the total SF-36 score improved. CONCLUSIONS FES cycling was reasonably well tolerated by progressive MS patients and encouraging improvements were seen in walking and quality-of-life. Larger studies of FES cycling in progressive MS are indicated.

Objective Assessment of Gait in Normal-Pressure Hydrocephalus

Williams MA, Thomas G, de Lateur B, Imteyaz H, Rose JG, Shore WS, Kharkar S, Rigamonti D: Objective assessment of gait in normal-pressure hydrocephalus. Am J Phys Med Rehabil 2008;87:39–45. Objectives:Gait abnormalities are an early clinical symptom in normal pressure hydrocephalus (NPH), and subjective improvement in gait after temporary removal of CSF is often used to decide to perform shunt surgery. We investigated objective measures to compare gait before and after CSF drainage and shunt surgery. Design:Twenty patients and nine controls were studied. Quantitative gait measures were obtained at baseline, after 3 days of controlled CSF drainage, and after shunt surgery. Decision to perform surgery was based on response to drainage, and patients were assigned to shunted or unshunted groups for comparison. Results:There was no improvement after CSF drainage in the unshunted group (n = 4). In the shunted group (n = 15) velocity, double-support time, and cadence improved significantly after drainage, and improved further after shunt surgery. The degree of improvement after drainage significantly correlated to the degree of improvement postshunt for velocity, double-support time, cadence, and stride length. Conclusions:There are significant, quantifiable changes in gait after CSF drainage that correspond to improvement after shunt surgery for patients with NPH. Use of objective gait assessment may improve the process of identifying these candidates when response to CSF removal is used as a supplemental prognostic test for shunt surgery.

Functional outcomes in Rett syndrome

AIM To relate functional outcomes to mutation type and age at evaluation in patients with Rett syndrome (RTT). METHOD We identified 96 RTT patients with mutations in the MECP2 (methyl-CpG-binding protein 2) gene. Chart analysis, clinical evaluation, and functional measures were completed. RESULTS Among 11 mutation groups, a statistically significant group effect of mutation type was observed for self-care, upper extremity function, and mobility, on standardized measures administered by occupational and physical therapists. Patients with R133C and uncommon mutations tended to perform best on upper extremity and self-care items, whereas patients with R133C, R306C and R294X had the highest scores on the mobility items. The worst performers on upper extremity and self-care items were patients with large deletions, R255X, R168X, and T158M mutations. The lowest scores for mobility were found in patients with T158M, R255X, R168X, and R270X mutations. On categorical variables as reported by parents at the time of initial evaluation, patients with R133C and R294X were most likely to have hand use, those with R133C, R294X, R306C and small deletions were most likely to be ambulatory, and those with R133C were most likely to be verbal. INTERPRETATION Functional performance in RTT patients may relate to the type of mutation. Knowledge of these relationships is useful for developing appropriate rehabilitation strategies and prognosis.

A Portable Device for Quantification of Forearm Muscle Tone

The ability to objectively quantify muscle tone is important in the assessment of theeffectiveness of therapeutic intervention in persons with spasticity and other conditionsassociatedwithuppermotorneurondisorders.Spasticityisdefinedasavelocity-dependenthypertonia caused by an abnormally high involuntary contraction of a muscle or group ofmuscles due to a rate-dependent reflex mechanism [1,2]. Tone, or resistance to externalstretch, can be modeled mathematically with the use of viscoelastic parameters when onemeasuresthetorqueanddisplacementofaperturbation.Inthisbriefreport,wedescribethedesignandinitialimplementationofanoveldirect-driveroboticdevicethatprovidesawiderange of displacement trajectories for the identification of limb viscoelastic parameters.Current assessments of tone, such as the Ashworth Scale [3], are subjective andqualitativeinnatureandhavebeenshowntobeunreliable[4,5].Newmethodsareneeded.[2,5-7]. Although electromyography (EMG) measurements are useful for monitoring thetimingofreflexresponsestests,theyarenotidealforquantifyingmuscletonebecauseEMGsignals can be extremely “noisy.” Although electromyography (EMG) measurements areuseful for monitoring the timing of reflex responses, they are not ideal for quantifyingmuscle tone, because EMG signals can be extremely noisy. EMG magnitude is correlatedwith the active force produced by the muscle. However, the exact relationship is complexand can vary among subjects due to electrode placement and the nature of the contraction[5,7], particularly when the magnitude of the noise is similar to that of the EMG.

Recruitment and Retention Issues in Clinical Trials

Advances in exercise interventions and new medications are best documented by clinical trials. It seems intuitive that subjects with relevant conditions or diseases would be eager to participate in such trials, from which they may benefit and, in some cases, also receive monetary compensation. However, frequent and severe recruitment difficulties are encountered for randomized, controlled trials of new medications, often prompting large pharmaceutical companies to recruit subjects from developing countries where rules are less restrictive [1]. Of 3 clinical trials for which we have been investigators, 2 were randomized controlled rials, and in 1 trial we studied the biomechanical effects of and magnetic resonance imaging ndings for a medication that is the standard-of-care drug in the multiple sclerosis clinic of ur institution. All 3 trials had to be discontinued at one stage or another because of nsufficient subjects. Figure 1 shows a typical recruitment algorithm that applies to each of the 3 studies for hich we were investigators. The first study was conducted to compare the effects of wimming at warm (92°F) and cool (82°F) temperatures on weight changes without dieting n moderately obese postmenopausal women (the study included a treadmill control roup). Of 30 women initially recruited, 15 completed the study. In addition to potential ealth benefits, incentives included

RELATIVE STRENGTH PREDICTS FUNCTION EVEN IN THE OBESE: LETTERS TO THE EDITOR

25 for the first physical,

A COMPARISON OF GAIT ASSESSMENT METHODS: TINETTI AND GAITRITE ELECTRONIC WALKWAY

50 for the last physical,

Doing well: A SEM analysis of the relationships between various activities of daily living and geriatric well-being

4 for ach swim session (resulting in a total of

Prevention and Treatment of Frailty in the Postmenopausal Woman

256 for sessions),

Exercise Following Burn Injury

5 for each diet/activity log resulting in a total of