Clinical practice recommendations for management of lateropulsion after stroke determined by a Delphi expert panel

OBJECTIVE

People exhibiting post-stroke lateropulsion actively push their body across the midline to the more affected side and/or resist weight shift toward the less affected side. Despite its prevalence and associated negative rehabilitation outcomes, no clinical practice guidelines exist for the rehabilitation of post-stroke lateropulsion. We aimed to develop consensus-based clinical practice recommendations for managing post-stroke lateropulsion using an international expert panel.

DESIGN

This Delphi panel process conformed with Guidance on Conducting and Reporting Delphi Studies recommendations.

PARTICIPANTS

Panel members had demonstrated clinical and/or scientific background in the rehabilitation of people with post-stroke lateropulsion.

MAIN MEASURES

The process consisted of four electronic survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One. Consensus was defined a priori as ≥75% agreement (agree or strongly agree), or ≥70% agreement after excluding 'unsure' responses.

RESULTS

Twenty participants completed all four rounds. Consensus was achieved regarding a total of 119 recommendations for rehabilitation approaches and considerations for rehabilitation delivery, positioning, managing fear of falling and fatigue, optimal therapy dose, and discharge planning. Statements for which 'some agreement' (50%-74% agreement) was achieved and those for which recommendations remain to be clarified were recorded.

CONCLUSIONS

These recommendations build on existing evidence to guide the selection of interventions for post-stroke lateropulsion. Future research is required to elaborate specific rehabilitation strategies, consider the impact of additional cognitive and perceptual impairments, describe positioning options, and detail optimal therapy dose for people with lateropulsion.

Post-stroke lateropulsion terminology: pushing for agreement amongst experts

Post-stroke lateropulsion is prevalent. The global inconsistency in terminology used to describe the condition presents obstacles in accurately comparing research results, reaching consensus on use of measurement tools, agreeing upon a consistent approach to rehabilitation, and translating research to clinical practice. Commencing in 2021, 20 international experts undertook a Delphi Process that aimed to compile clinical practice recommendations for the rehabilitation of lateropulsion. As a part of the process, the panel agreed to aim to reach consensus regarding terminology used to describe the condition. Improved understanding of the condition could lead to improved management, which will enhance patient outcomes after stroke and increase efficiency of healthcare resource utilisation. While consensus was not reached, the panel achieved some agreement that 'lateropulsion' is the preferred term to describe the phenomenon of 'active pushing of the body across the midline toward the more affected side, and / or actively resisting weight shift toward the less affected side'. This group recommends that 'lateropulsion' is used in future research and in clinical practice.

Immunogenicity induced by botulinum toxin injections for limb spasticity: A systematic review

BACKGROUND

The imputability of neutralizing antibodies (NABs) in secondary non-response (SnR) to botulinum toxin (BoNT) injections for limb spasticity is still debated.

OBJECTIVE

This systematic literature review aimed to determine the prevalence of NABs after BoNT injections for limb spasticity and analyze their determinants and their causal role in SnR.

METHODS

We searched MEDLINE via PubMed, Cochrane and Embase databases for articles published during 1990-2018. Two independent reviewers extracted the data and assessed the quality of studies with a specific scale (according to PRISMA and STROBE guidelines). Because the techniques used to detect NABs did not influence the results, we calculated the global (all studies) sensitivity and specificity of NAB positivity to reveal SnR.

RESULTS

We included 14 articles published from 2002 to 2018 (including an epublication) describing 5 randomized controlled trials and 5 interventional and 4 observational studies. The quality was satisfactory (mean score 18/28 arbitrary units). NAB detection was the primary criterion in 5 studies and a secondary criterion in 9. In total, 1234 serum samples for 1234 participants (91% with stroke) were tested after injection. NAB prevalence was about 1%, with no significant difference among formulations. NAB positivity seemed favoured by long-duration therapy with high doses and a short interval between injections. The identification of non-response by NAB positivity had poor global sensitivity (56%) but very high specificity (99.6%). No consensual criteria were used to diagnose non-response to BoNT injection.

CONCLUSIONS

NAB prevalence is much lower after BoNT treatment for limb spasticity than cervical dystonia. Consensual criteria must be defined to diagnose non-response to BoNT injection. Because immunogenicity is not the most common cause of non-response to BoNT injection, NABs should be sought in individuals with SnR with no other cause explaining the treatment inefficacy. A test with 100% specificity is recommended. In cases for which immunogenicity is the most likely cause of non-response to BoNT injections, some biological arguments suggest trying another BoNT, but no clinical evidence supports this strategy.

Postural control in healthy young adults using a double seesaw device

Postural control on single and double seesaws was investigated in young healthy adults required to stand as still as possible on two side-by-side seesaws favoring pitch motion and lying on two separate force platforms. The device offers the possibility to get associated or dissociated seesaws and, if dissociated, to induce asymmetric patterns for the centers-of-pressure (CP) under both left and right feet by using different radii for the two seesaws. Substituting a parallelepiped volume to one seesaw offering a firm contact to one foot is also possible. The results indicated that dissociating the two seesaws led to increased resultant CP (CP_Res) and vertically projected center-of-gravity movements (CG_v) only along the mediolateral axis, whereas a slight decreasing tendency characterized these movements along the antero-posterior axis. When standing on two independent seesaws with different radii, significantly larger CP displacements were seen along the antero-posterior axis under the foot lying on the more stable support, i.e., the seesaw with the longer radius or the parallelepiped volume. In these two asymmetrical conditions, the CP_Res output results from a compensatory mechanism, i.e. larger movements under one foot to compensate for the decreased movements occurring under the opposite foot. This postural control strategy is aimed at allowing sufficient CP_Res displacements in order to appropriately secure balance. Because of the complex sensorimotor coordination induced, involving differentially in certain cases both legs, the double seesaw device can be viewed as a possible tool for challenging postural control by inducing asymmetrical patterns between left and right feet CP movements.

Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study

INTRODUCTION

Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke.

METHODS AND ANALYSIS

220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored.

ETHICS AND DISSEMINATION

Patients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients.

TRIAL REGISTRATION NUMBER

NCT02944929.

Speech recovery and language plasticity can be facilitated by Sensori-Motor Fusion training in chronic non-fluent aphasia. A case report study

The rehabilitation of speech disorders benefits from providing visual information which may improve speech motor plans in patients. We tested the proof of concept of a rehabilitation method (Sensori-Motor Fusion, SMF; Ultraspeech player) in one post-stroke patient presenting chronic non-fluent aphasia. SMF allows visualisation by the patient of target tongue and lips movements using high-speed ultrasound and video imaging. This can improve the patient's awareness of his/her own lingual and labial movements, which can, in turn, improve the representation of articulatory movements and increase the ability to coordinate and combine articulatory gestures. The auditory and oro-sensory feedback received by the patient as a result of his/her own pronunciation can be integrated with the target articulatory movements they watch. Thus, this method is founded on sensorimotor integration during speech. The SMF effect on this patient was assessed through qualitative comparison of language scores and quantitative analysis of acoustic parameters measured in a speech production task, before and after rehabilitation. We also investigated cerebral patterns of language reorganisation for rhyme detection and syllable repetition, to evaluate the influence of SMF on phonological-phonetic processes. Our results showed that SMF had a beneficial effect on this patient who qualitatively improved in naming, reading, word repetition and rhyme judgment tasks. Quantitative measurements of acoustic parameters indicate that the patient's production of vowels and syllables also improved. Compared with pre-SMF, the fMRI data in the post-SMF session revealed the activation of cerebral regions related to articulatory, auditory and somatosensory processes, which were expected to be recruited by SMF. We discuss neurocognitive and linguistic mechanisms which may explain speech improvement after SMF, as well as the advantages of using this speech rehabilitation method.

Dynamics of clinical recovery during the early phase of rehabilitation in patients with severe traumatic and non-traumatic brain injury

PURPOSE

Our aim was to describe the changes in the functional outcome at the early phase of rehabilitation following severe brain injury and to identify the factors associated with faster recovery.

METHODS

This retrospective analysis included 182 patients who were transferred from the intensive care unit (ICU) to a post-ICU neurorehabilitation unit following traumatic brain injury (TBI) (n = 82) or cerebrovascular accident (CVA) (n = 100). Admission, discharge and changes in scores were calculated for the Functional Independent Measurement (FIM) and the Wessex Head Injury Matrix (WHIM). Patients with high dynamics of clinical recovery were defined by delta FIM scores ≥22.

RESULTS

Upon admission to the neurorehabilitation unit, 97% of patients had a FIM score <50 and 41% a WHIM score <32. Patients showed significantly improved FIM (+17 points; 7-37) and WHIM (+11 points; 3-19) scores with an over 22-day stay (14-38). Those with faster recovery (45%) were more likely those with high FIM and WHIM scores at admission. The nature and severity of the brain insult were not associated with the dynamics of recovery.

CONCLUSIONS

Within a 2-6 week stay in a post-ICU neurorehabilitation unit, patients with severe disability could achieve partial functional independence and showed cognitive improvements.

Selecting a test for the clinical assessment of balance and walking capacity at the definitive fitting state after unilateral amputation: a comparative study

BACKGROUND

There is a lack of data and consensus concerning the most appropriate functional evaluation in clinical practice at the definitive prosthetic phase after lower limb amputation.

OBJECTIVES

To determine among several selected functional tests the most pertinent to evaluate balance and prosthetic walking.

STUDY DESIGN

Validation of a diagnostic procedure.

METHODS

Sixty-four patients were included.

OUTCOME MEASURES

Timed Up and Go test, Functional Reach test (FRT), one-leg balance, tandem test, Modified Houghton Scale, Berg Balance Scale, two-minute walk test (2MW test). Correlations were assessed with the Pearson correlation coefficient and the Principal Component Analysis. Score distribution was analyzed with the Shapiro-Wilk W normality test. Receiver operating characteristic curves were drawn to identify the best predictor for the function.

RESULTS

The clinical tests correlated highly with each other. Only 2MW test and FRT did not have either a floor/ceiling effect, or a bi-modal distribution. The 2MW test was the best predictor of prosthetic walking limitations (area under the curve 0.93 (0.83-0.97), the best threshold was between 130 and 150 meters), and FRT was best for balance.

CONCLUSIONS

2MW test can be proposed as the first-line clinical test. The FRT can be indicated for the specific assessment of balance disorders. Clinical relevance This validation of a clinical evaluation of balance and walking capacity after lower limb amputation may be useful in everyday practice to ensure in a simple and standardized way the follow-up of patients and adapt treatments--especially prosthetics--at the definitive prosthetic phase.

The adolescent and adult form of cobalamin C disease: clinical and molecular spectrum

BACKGROUND

Cobalamin C disease is the most common inborn error of cobalamin metabolism with an autosomal recessive mode of inheritance and mutations within the MMACHC gene. Clinical features, including systemic, haematological and neurological abnormalities, usually occur in the first year of life. Adolescent and adult onset presentations are rare.

METHODS

We report on the clinical, molecular and imaging features in three patients aged 40, 42 and 42 years at the last follow-up. We examine these cases together with eight previously described cases to determine the clinical and molecular features of the disease in adults.

RESULTS

Mean age at onset of clinical symptoms was 26 years; clinical features included predominant neurological disturbances and thromboembolic complications. White matter abnormalities on brain MRI were sometimes observed. Most patients (eight of nine patients investigated) were compound heterozygotes for the 271dupA mutation and a missense mutation. Intramuscular or intravenous hydroxycobalamin therapy stopped the progression of the disease and resulted in a better clinical outcome and favourable biological status in 7/9 treated cases, while the two untreated patients died quickly.

CONCLUSIONS

As cobalamin C disease and related disorders of homocysteine metabolism are treatable conditions, homocysteinaemia should be included in the investigations of patients with progressive neurological deterioration, unexplained psychiatric disturbances or recurrent thromboembolic events.

A battery of tests for the quantitative assessment of unilateral neglect

PURPOSE

The lack of agreement regarding assessment methods is responsible for the variability in the reported rate of occurrence of unilateral neglect (UN) after stroke. In addition, dissociations have been reported between performance on traditional paper-and-pencil tests and UN in everyday life situations.

METHODS

In this paper, we present the validation studies of a quantitative test battery for UN, including paper-and-pencil tests, an assessment of personal neglect, extinction, and anosognosia, and a behavioural assessment, the Catherine Bergego Scale (CBS). The battery was given to healthy subjects (n=456-476) and to patients with subacute stroke, either of the right or the left hemisphere.

RESULTS

In healthy subjects, a significant effect of age, education duration and acting hand was found in several tasks. In patients with right hemisphere stroke, the most sensitive paper and pencil measure was the starting point in the cancellation task. The whole battery was more sensitive than any single test alone. An important finding was that behavioural assessment was more sensitive than any other single test. Neglect was two to four times less frequent, but also less severe and less consistent after left hemisphere stroke.

CONCLUSION

Assessment of UN should rely on a battery of quantitative and standardised tests. Some patients may show clinically significant UN in everyday life while obtaining a normal performance on paper-and-pencil measures. This underlines the necessity to use a behavioural assessment of UN.

Right spatial neglect after left hemisphere stroke: qualitative and quantitative study

OBJECTIVES

Comparatively little research has been conducted on right neglect after left brain damage. The authors sought to assess contralateral neglect in subacute left hemisphere stroke patients using a comprehensive test battery validated in a large control group after right hemisphere stroke.

METHODS

Seventy-eight left hemisphere stroke patients were assessed. The test battery included a preliminary assessment of anosognosia and visual extinction, a clinical assessment of gaze orientation and personal neglect, and paper-and-pencil tests of spatial neglect in the peripersonal space. Only nonverbal tests were used.

RESULTS

Drawing and cancellation tasks revealed neglect in 10 to 13% of patients. The combined battery was more sensitive than any single test alone. A total of 43.5% of patients showed some degree of neglect on at least one measure. Anatomic analyses showed that neglect was more common and severe when the posterior association cortex was damaged.

CONCLUSIONS

The frequency of occurrence of right neglect was, as expected, much lower than that reported in a study using the same assessment battery in right brain damage stroke patients. Nevertheless, neglect was found in a substantial proportion of patients at a subacute stage, suggesting that it should be considered in the rehabilitation planning of left brain damage stroke patients.

[Assessment of idiopathic Parkinson's disease in physical medicine and rehabilitation]

Parkinson's disease (PD) is a chronic disease associated with motor impairments (bradykinesia, rigidity, tremor and postural disorders), cognitive disorders and dysautonomia. Most symptoms are greatly improved by dopatherapy during the first stages, then signs of treatment ineffectiveness or intolerance occur that signal the beginning of motor and cognitive decline. This evolution signified the need to develop an effective tool to measure the effectiveness of drugs or surgery in PD and has had the Movement Disorder Society to propose 20 years ago a tool to assess such patients: the Unified Parkinson's Disease Rating Scale (UPDRS). This scale has a good internal consistency and a good interrater reliability. Yet, some impairments, especially of cognitive origin, are evaluated too succinctly and need complementary scales. As well, other disorders such as bladder disorders are not included, nor is quality of life studied despite the impact of PD on daily life. Specific scales have been proposed. UPDRS may be well-adapted to PD follow-up in the physical medicine and rehabilitation context by measuring treatment effectiveness, detecting Dopa ineffectiveness or complications and assessing patients' handicap in daily activities. The evolution of UPDRS will improve the qualities of the scale and contribute to better determining the various stages of the disease.

Validation of the Aphasic Depression Rating Scale

Background and Purpose— The Aphasic Depression Rating Scale (ADRS) was developed to detect and measure depression in aphasic patients during the subacute stage of stroke.

Methods— Six experts selected an initial sampling of behavioral items from existing depression rating scales. Stroke patients (aphasic and nonaphasic) were assessed with these items by the rehabilitation staff, with the Hamilton Depression Rating Scale (HDRS) for nonaphasic patients only, by a psychiatrist, and by the rehabilitation staff with Visual Analog Scales (VAS). A second item selection was conducted after a regression algorithm was run including VAS as independent variables (criterion validity) and after their factorial structure was analyzed with a principal component analysis (factorial validity). The construct validity was evaluated with respect to the other depression assessments. A threshold for the diagnosis of depression was computed with respect to the psychiatrist’s diagnosis. Interrater and test-retest reliability were assessed in 2 additional groups of aphasic patients.

Results— Eighty patients participated in the study (59 aphasic). Fifteen behavioral items from existing depression rating scales were selected, and 9 were retained after the validation process. ADRS correlated highly with VAS and HDRS ( r =0.60 to 0.78, P =10 −4 to 10 −6 ). With respect to the psychiatrist’s diagnosis, the sensitivity and specificity of ADRS were 0.83 and 0.71, respectively, when the threshold was set at 9/32. Its factorial structure was comparable to HDRS structure. Interrater and test-retest reliability were high (average κ coefficient of the 9 items=0.69).

Conclusions— ADRS is a valid, reliable, sensitive, and specific tool for the evaluation of depression in aphasic patients during the stroke subacute phase.

Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke

OBJECTIVES

The lack of agreement regarding assessment methods is responsible for the variability in the reported rate of occurrence of spatial neglect after stroke. The aim of this study was to assess the sensitivity of different tests of neglect after right hemisphere stroke.

METHODS

Two hundred and six subacute right hemisphere stroke patients were given a test battery including a preliminary assessment of anosognosia and of visual extinction, a clinical assessment of gaze orientation and of personal neglect, and paper and pencil tests of spatial neglect in the peripersonal space. Patients were compared with a previously reported control group. A subgroup of patients (n=69) received a behavioural assessment of neglect in daily life situations.

RESULTS

The most sensitive paper and pencil measure was the starting point in the cancellation task. The whole battery was more sensitive than any single test alone. About 85% of patients presented some degree of neglect on at least one measure. An important finding was that behavioural assessment of neglect in daily life was more sensitive than any other single measure of neglect. Behavioural neglect was considered as moderate to severe in 36% of cases. A factorial analysis revealed that paper and pencil tests were related to two underlying factors. Dissociations were found between extrapersonal neglect, personal neglect, anosognosia, and extinction. Anatomical analyses showed that neglect was more common and severe when the posterior association cortex was damaged.

CONCLUSIONS

The automatic rightward orientation bias is the most sensitive clinical measure of neglect. Behavioural assessment is more sensitive than any single paper and pencil test. The results also support the assumption that neglect is a heterogeneous disorder.

[Presenting a battery for assessing spatial neglect. Norms and effects of age, educational level, sex, hand and laterality]

The aim of this study was to build up a battery for assessing spatial neglect, then to analyse the norms and potential effects of age, education level, sex, hand used, and laterality. It was also to contribute evaluating the pseudoneglect phenomenon described by Heilman, which consists in a tendency of normal subjects to neglect the right peripersonal space. Tasks selected were presented to important groups of normal subjects, most often larger than 450. The battery comprised of a bell cancellation test, scene copy, clock drawing, two line bisection tasks, identification of overlapping figures, text reading, writing task, and the representational task of the France map. For each of them, different variables were selected, especially investigating the difference between performance in the right and the left hemispaces. This study allowed defining the threshold values (percentiles 5 and 95) for deciding of the pathological character of a patient performance. It also showed that the pseudoneglect phenomenon is more obvious in some tasks such as line bisection, and probably also in the representational task of the France map and writing. His importance and at times his side were influenced by the factors we studied, with between tasks differences, but also by the nature of the task to be performed, and especially his verbal component.