Carry-over fluency induced by extreme prolongations: A new behavioral paradigm

Extreme prolongations, which can be generated via extreme delayed auditory feedback (DAF) (e.g., 250-500 ms) or mediated cognitively with timing applications (e.g., analog stopwatch) at 2 s per syllable, have long been behavioral techniques used to inhibit stuttering. Some therapies have used this rate solely to establish initial fluency, while others use extremely slowed speech to establish fluency and add other strategic techniques such as easy onsets and diaphragmatic breathing. Extreme prolongations generate effective, efficient, and immediate forward flowing fluent speech, removing the signature behaviors of discrete stuttering (i.e., syllable repetitions and audible and inaudible postural fixations). Prolonged use of extreme prolongations establishes carry-over fluency, which is spontaneous, effortless speech absent of most, if not all, overt and covert manifestations of stuttering. The creation of this immediate fluency and the immense potential of extreme prolongations to generate long periods of carry-over fluency have been overlooked by researchers and clinicians alike. Clinicians depart from these longer prolongation durations as they attempt to achieve the same fluent results at a near normal rate of speech. Clinicians assume they are re-teaching fluency and slow rates will give rise to more normal rates with less control, but without carry-over fluency, controls and cognitive mediation are always needed for the inherently unstable speech systems of persons who stutter to experience fluent speech. The assumption being that the speech system is untenable without some level of cognitive and motoric monitoring that is always necessary. The goal is omnipresent "near normal rate sounding fluency" with continuous mediation via cognitive and motoric processes. This pursuit of "normal sounding fluency" continues despite ever-present relapse. Relapse has become so common that acceptance of stuttering is the new therapy modality because relapse has come to be understood as somewhat inevitable. Researchers and clinicians fail to recognize that immediate amelioration of stuttering and its attendant carry-over fluency are signs of a different pathway to fluency. In this path, clinicians focus on extreme prolongations and the extent of their carry-over. While fluency is automatically generated under these extreme prolongations, the realization is that communication at this rate in routine speaking tasks is not feasible. The perceived solution is a systematic reduction in the duration of these prolongations, which attempts to approximate "normal speech." Typically, the reintroduction of speech at a normalized rate precipitates a laborious style that is undesirable to the person who stutters (PWS) and is discontinued, once departed from the comforts of the clinical setting. The inevitable typically occurs; the well-intentioned therapist instructs the PWS to focus on the techniques while speaking at a rate that is nearest normal speech, but the overlooked extreme prolongations are unlikely to ever be revisited. The foundation of this hypothesis is that the departure from fluency generators (e.g. extreme prolongations) is the cause of regression to the stuttering set point. In turn, we postulate that the continued use of extreme prolongations, as a solitary practice method, will establish and nurture different neural pathways that will create a modality of fluent speech, able to be experienced without cognitive or motoric mediation. This would therefore result in fewer occurrences of stuttering due to a phenomenon called carry-over fluency. Thus, we hypothesize that the use of extreme prolongations fosters neural pathways for fluent speech, which will result in carry-over fluency that does not require mediation by the speaker.

A pilot study of a comparison between a patient scored numeric rating scale and clinician scored measures of spasticity in multiple sclerosis

OBJECTIVE

To assess the validity and reliability of a Numeric Rating Scale (NRS) for the measurement of spasticity in multiple sclerosis.

DESIGN

Longitudinal study with multiple comparators over two clinic visits.

SETTING

Rehabilitation Centre in the North East of England, UK.

SUBJECTS

A total of thirty-five patients, with a diagnosis of multiple sclerosis (MS) that were attending a rehabilitation clinic.

RESULTS

The test/re-test reliability of the NRS showed there was a high correlation between the two visits (r = 0.672). Construct validity was assessed by examining the relationship between the mean spasticity NRS and each of the other spasticity assessment tools. There was a statistically significant correlation between subject's mean NRS diary scores and the Modified Ashworth Scale scores at both visits (Visit 1, r = 0.459, p = 0.0056; Visit 2, r = 0.446, p = 0.0106). There was a moderate, statistically significant correlation between the mean NRS diary scores and the Tardieu Scale (Visit 1, r = 0.429, p = 0.0113; Visit 2, r = 0.407, p = 0.0209).

CONCLUSIONS

The spasticity NRS has been shown to be a valid and reliable tool in the assessment of spasticity with a moderate to high level of correlation with other clinician rated instruments used to assess spasticity.

EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force

Post-polio syndrome (PPS) is characterized by new or increased muscular weakness, atrophy, muscle pain and fatigue several years after acute polio. The aim of the article is to prepare diagnostic criteria for PPS, and to evaluate the existing evidence for therapeutic interventions. The Medline, EMBASE and ISI databases were searched. Consensus in the group was reached after discussion by e-mail. We recommend Halstead's definition of PPS from 1991 as diagnostic criteria. Supervised, aerobic muscular training, both isokinetic and isometric, is a safe and effective way to prevent further decline for patients with moderate weakness (Level B). Muscular training can also improve muscular fatigue, muscle weakness and pain. Training in a warm climate and non-swimming water exercises are particularly useful (Level B). Respiratory muscle training can improve pulmonary function. Recognition of respiratory impairment and early introduction of non-invasive ventilatory aids prevent or delay further respiratory decline and the need for invasive respiratory aid (Level C). Group training, regular follow-up and patient education are useful for the patients' mental status and well-being. Weight loss, adjustment and introduction of properly fitted assistive devices should be considered (good practice points). A small number of controlled studies of potential-specific treatments for PPS have been completed, but no definitive therapeutic effect has been reported for the agents evaluated (pyridostigmine, corticosteroids, amantadine). Future randomized trials should particularly address the treatment of pain, which is commonly reported by PPS patients. There is also a need for studies evaluating the long-term effects of muscular training.

A systematic review on the diagnosis and treatment of primary (idiopathic) dystonia and dystonia plus syndromes: report of an EFNS/MDS-ES Task Force

To review the literature on primary dystonia and dystonia plus and to provide evidence-based recommendations. Primary dystonia and dystonia plus are chronic and often disabling conditions with a widespread spectrum mainly in young people. Computerized MEDLINE and EMBASE literature reviews (1966-1967 February 2005) were conducted. The Cochrane Library was searched for relevant citations. Diagnosis and classification of dystonia are highly relevant for providing appropriate management and prognostic information, and genetic counselling. Expert observation is suggested. DYT-1 gene testing in conjunction with genetic counselling is recommended for patients with primary dystonia with onset before age 30 years and in those with an affected relative with early onset. Positive genetic testing for dystonia (e.g. DYT-1) is not sufficient to make diagnosis of dystonia. Individuals with myoclonus should be tested for the epsilon-sarcoglycan gene (DYT-11). A levodopa trial is warranted in every patient with early onset dystonia without an alternative diagnosis. Brain imaging is not routinely required when there is a confident diagnosis of primary dystonia in adult patients, whereas it is necessary in the paediatric population. Botulinum toxin (BoNT) type A (or type B if there is resistance to type A) can be regarded as first line treatment for primary cranial (excluding oromandibular) or cervical dystonia and can be effective in writing dystonia. Actual evidence is lacking on direct comparison of the clinical efficacy and safety of BoNT-A vs. BoNT-B. Pallidal deep brain stimulation (DBS) is considered a good option, particularly for generalized or cervical dystonia, after medication or BoNT have failed to provide adequate improvement. Selective peripheral denervation is a safe procedure that is indicated exclusively in cervical dystonia. Intrathecal baclofen can be indicated in patients where secondary dystonia is combined with spasticity. The absolute and comparative efficacy and tolerability of drugs in dystonia, including anticholinergic and antidopaminergic drugs, is poorly documented and no evidence-based recommendations can be made to guide prescribing.

The use of botulinum toxin type-B in the treatment of patients who have become unresponsive to botulinum toxin type-A -- initial experiences

The increasing use of botulinum toxin type-A, especially for focal dystonia and spasticity has highlighted the issue of secondary non-responsiveness. Within the last few years botulinum toxin type-B (Myobloc/Neurobloc) has become commercially available as an alternative to type-A. This paper discusses our initial experience of botulinum toxin type-B in a total of 63 individuals who attended our botulinum clinic. Thirty-six patients had cervical dystonia and a secondary non-response to type-A toxin. Thirteen of these patients (36%) had a reasonable clinical response to Neurobloc and continue to have injections. The other 23 patients either had no response, or a poor response, or had unacceptable side effects and ceased treatment. A small number of people with blepharospasm, hemifacial spasm and foot dystonia also had a disappointing response to injection. Twenty patients with spasticity were also type-A resistant. Seven of these show some continuing response to type-B, without unacceptable side effects. These findings demonstrate that botulinum toxin type-B has a place in the management of patients who have become non-responsive to type-A, but overall the responses to type-B toxin were disappointing.

Does spasticity result from hyperactive stretch reflexes? Preliminary findings from a stretch reflex characterization study

PURPOSE

To characterize the stretch reflex response of the biceps brachii in stroke patients with elbow spasticity (prior to or within 15 min of treatment with botulinum toxin) and non-impaired volunteers with the aim of quantifying the stretch reflex excitability and observe the differences between the groups.

METHODS

A cross-sectional study. Stretch reflexes from the biceps brachii were elicited following a controlled elbow extension. The amplitude, latency, rise time and duration, calculated from surface EMG recordings from the biceps brachii, were used to characterize the stretch reflex response.

RESULTS

Seventeen non-impaired and 14 stroke patients participated. The amplitude was significantly lower in stroke patients than in non-impaired volunteers (p<0.05). The latency was significantly shorter in stroke patients than in non-impaired volunteers (p<0.05). There were no significant differences in rise time or duration (p>0.10).

DISCUSSION

Reduction in the amplitude in stroke patients was unexpected suggesting the stretch reflex is not necessarily hyper-excitable in people with clinically diagnosed spasticity. Latency differences suggest decreased presynaptic inhibition and/or increased motor neurone excitability can occur following a stroke. However, carry over effects from previous botulinum toxin treatment may have confounded amplitude measurements. Further work evaluating the excitability of the stretch reflex independent of Botulinum toxin and its contribution to resistance to passive stretching is being conducted.

Spasticity in multiple sclerosis

The objective of this article is to establish the prevalence of spasticity in a random selection of people with multiple sclerosis (MS) in the city of Newcastle upon Tyne in the Northeast of England. A secondary aim was to assess the adequacy of current pharmacological intervention for spasticity and assess the relationship between spasticity and overall disability. The study design was a simple comparison that examined differences in functional independence in 2 random groups of people with MS subdivided by the presence of clinically significant spasticity. A total of 68 adults with a diagnosis of clinically definite MS were included in the study. Their level of functional independence was assessed using the Newcastle Independence Assessment Form (NIAF), the Functional Independence Measure (FIM), and the Kurtzke Extended Disability Status Scale (EDSS). Spasticity was assessed using the Modified Ashworth Scale. A subjective analysis was made of the appropriateness of oral antispastic medication by a rehabilitation physician. Thirty-two people (47%) had clinically significant spasticity (Modified Ashworth Score of 2, 3, or 4). Seventy-eight percent of the population were receiving some oral antispastic medication, but 50% were deemed to require some drug adjustment or additional treatment. Individuals with spasticity were found to have significantly higher levels of disability than those who had no spasticity or clinically insignificant spasticity. This study has confirmed that spasticity is highly prevalent in the MS population and is significantly associated with a reduced level of functional independence. Treatment of spasticity is suboptimal in a large proportion of the population, and the need for further information and education to health professionals and to people with MS is highlighted.

Assessing motor deficits in neurological rehabilitation: patterns of instrument usage

To describe current patterns in the use of clinical scales and measurement technology for the assessment of motor deficits in neurological rehabilitation. Questionnaire, sent to the 2,556 members of the World Forum for Neurological Rehabilitation, distributed over 75 countries. Sixty-eight questionnaires were returned. Generally, participants indicated that the centres where they were based used a number of different clinical assessment scales (median, three), most frequently with a small proportion of patients. The (Modified) Ashworth Scale, the FIM, and the Fugl-Meyer were used most frequently. Only 35 respondents stated that their centre used one or more scales in >75% of their patients, but the choice of such routinely applied instruments varied between centres. The application of measurement technology was restricted, with video and goniometry being used most frequently. The main barriers to more frequent use of assessment tools were perceived to be a lack of resources, information, and training. The (albeit limited) results from this survey suggest that the assessment of motor deficits in neurological rehabilitation is currently mostly qualitative and lacks standardisation. More resources and education are required to support a more routine application of assessment tools and to integrate measurement technology further in neurological rehabilitation to assist in the process of quantification of outcomes.

Biomechanical examination of a commonly used measure of spasticity

BACKGROUND

An increase in the prevalence of neurological disability puts pressure on service providers to restrict costs associated with rehabilitation. Spasticity is an important neurological impairment for which many novel and expensive treatment options now exist. The antispastic effects of these techniques remain unexplored due to a paucity of valid outcome measures.

AIM

To develop a biomechanical measure of resistance to passive movement, which could be used in routine clinical practice, and to examine the validity of the modified Ashworth scale.

STUDY DESIGN

Repeated measure cross-section study on 16 subjects who had a unilateral stroke one-week previously and had no elbow contractures.

OUTCOME MEASURES

Simultaneous measurement of resistance to passive movement using a custom built measuring device and the modified Ashworth scale. Passive range of movement and velocity were also measured. The "catch", a phenomenon associated with the modified Ashworth scale, was identified by the assessor using a horizontal visual analogue scale and biomechanically quantified using the residual calculated from a linear regression technique.

RESULTS

Half the study population had a modified Ashworth score greater than zero. The association between the two measures was poor (kappa=0.366). The speed and range of passive movement were greater in subjects with modified Ashworth score "0" (P<0.05). Resistance to passive movement was higher in the impaired arm (P<0.05) and tended to decrease with repeated measures and increasing speeds.

CONCLUSIONS

A device to measure resistance to passive movement at the elbow was developed. The modified Ashworth scale may not provide a valid measure of spasticity but a measure of resistance to passive movement in an acute stroke population.

RELEVANCE

Spasticity is an important neurological impairment for which many novel and expensive treatment options are being made available. There is a paucity of clinically usable outcomes to measure spasticity. A device to measure resistance to passive movement at the elbow, which was more reliable than the modified Ashworth scale was developed. This device may provide a much needed objective clinical measure to evaluate the efficacy of antispasticity treatment.

Neurological rehabilitation in the community

There is increasing pressure on health services around the world to provide more resources and facilities in the community. This is partly as a counterbalance to the increasing cost of hospital services and partly a recognition of the importance of local health facilities. Rehabilitation has generally been a hospital-based specialty and there now needs to be a change of focus, or at least an additional focus, towards community rehabilitation. This review article summarizes some of the models of community rehabilitation and the evidence for their effectiveness. Although there is a reasonable body of evidence for both the acceptability and effectiveness of community rehabilitation there is a clear need for further research.

Guidance for the preparation of neurological management guidelines by EFNS scientific task forces

The aim of an EFNS neurological management guideline is to provide guidance for clinical neurologists, other health care professionals and health care providers about important aspects of management of neurological disease. It represents the view of an expert task force appointed by the chairperson of the scientific committee with the agreement of the chairperson of a Scientist Panel. It will be a peer-reviewed statement of minimum desirable standards for the guidance of practice based on the best available evidence. It is not intended to have legally binding implications in individual cases.

Spasticity: a rehabilitation challenge in the elderly

There is no doubt that spasticity is a significant cause of disability in the elderly. Regrettably, it is a condition that is often poorly treated and can result in a range of unnecessary complications which can cause further problems for the disabled person and their family. There are now a number of effective treatment options. However, before such options are defined the specific goals of rehabilitation need to be clarified and an appropriate outcome measure chosen in order to determine when such goals are being met. The treatment should be multidisciplinary and input from both the physician and a physiotherapist is essential. Involvement of the elderly person with spasticity, and often their family, is also important in the education process. Simple physiotherapy interventions can be remarkably helpful, including attention to positioning and seating. The role of the physician initially focuses on oral medication. Although we still have older drugs including diazepam, baclofen and dantrolene there are now more modern drugs including tizanidine and, more recently, gabapentin. However, most spasticity is focal in origin and thus requires focal treatment. Although phenol nerve blocks are sometimes helpful the use of botulinum toxin is now to be highly recommended. There is now clear evidence of the efficacy of botulinum toxin, which has been a significant advance in our management of spasticity. More advanced and difficult to treat problems can be alleviated by intrathecal baclofen or sometimes intrathecal phenol or, as a last resort, surgical intervention. The advent of lycra garments for the overall management of more diffuse spasticity is now becoming both fashionable and effective.

CONCLUSION

The management of spasticity in the elderly person is a significant challenge to the rehabilitation team and a combined approach can produce significant benefit for the disabled elderly person.

Botulinum toxin for people with dystonia treated by an outreach nurse practitioner: a comparative study between a home and a clinic treatment service

OBJECTIVE

To study whether a trained outreach nurse practitioner could provide a service that is as good as, or better than, that provided at a hospital outpatient clinic for people who had been diagnosed with dystonia and required treatment with botulinum toxin.

DESIGN

Randomized trial.

SETTING

An outpatient department of a regional neurorehabilitation center and patients' homes in northern England.

PATIENTS

Eighty-nine patients with a clinical diagnosis of spasmodic torticollis, blepharospasm, or hemifacial spasm who had ongoing treatment of dystonia with botulinum injections.

INTERVENTIONS

Individuals were randomly allocated either to receive ongoing botulinum injections at home by the nurse practitioner or to continue attending the hospital outpatient clinic and be injected by medical staff.

MAIN OUTCOME MEASURES

The following measures were recorded at each visit: demographic descriptors, dosage of botulinum toxin, treatment interval, side-effect profile, external referrals, and a questionnaire to determine qualitative opinion.

RESULTS

Efficacy and duration of the botulinum was similar in both groups. Botulinum dosage and side-effect profiles were similar in both groups except for significantly less dysphagia (p < .018) in the home group (7 vs 24 occasions). Subjective opinion by the patients indicated statistically significant preference for home injections. Economic analysis indicated that the overall cost of the treatment was less in the home injection group (total cost per visit $36.90 [ pound 23.36] vs $79.00 [ pound 50.01]), but this difference was not statistically significant.

CONCLUSION

A trained outreach nurse practitioner provided a service that was as good as, and in certain aspects better than, that provided by a hospital outpatient clinic. The nurse practitioner provided a more flexible, much appreciated, safe, and cost-effective service for this client group. Wider use of outreach nurse practitioners for dystonia should be encouraged.

An epidemiological survey of the health needs of disabled people in a rural community

OBJECTIVE

To describe service use and unmet needs of disabled people in a rural environment, given well-recognized difficulties in providing equitable services to a widely-spread population, availability of transport and the presence of discrepancies in wealth.

PARTICIPANTS

Disabled people registered with a single rural general practice, identified by postal questionnaire.

METHOD

All 3462 households were screened using the Office of Population, Censuses and Surveys (OPCS) disability screening questionnaire. An 86% response rate was achieved. Seventy-four people aged 16-65 and 69 people aged 66-75 were interviewed by a rehabilitation physician. Fifty-five people aged 76+ were interviewed. Disability was assessed using the OPCS scales of disability, Barthel Index, and Hospital Anxiety and Depression Scale.

RESULTS

Thirty per cent (43) of those aged 16-75 received assistance for their personal activities of daily living (ADLs), and 98% (140) required assistance for extended ADLs (taken from the OPCS surveys criteria). There was no difference in either disability or dependency by age group. Fifty-three per cent of this group had domestic adaptations, 75% had disability aids. Those aged 16-75 had significantly fewer aids and adaptations, less home care, care management, respite, district nursing and chiropody services than people over 75. Equipment was provided by statutory services less frequently and fewer carers were salaried. The rehabilitation physician assessed them as needing more occupational therapy, physiotherapy and chiropody. Thirty per cent saw their GP monthly and 45% attended hospital.

CONCLUSION

Unmet need was assessed as greater in the younger group. Elderly people are possibly more visible to service providers with better recognition of need. There is no evidence of a relationship between medical surveillance and identification of rehabilitation needs. Those with greater degrees of disability require more interlinked and organized services.

A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity

BACKGROUND

The Ashworth Scale and the modified Ashworth Scale are the primary clinical measures of spast city. A prerequisite for using any scale is a knowledge of its characteristics and limitations, as these will play a part in analysing and interpreting the data. Despite the current emphasis on treating spasticity, clinicians rarely measure it.

OBJECTIVES

To determine the validity and the reliability of the Ashworth and modified Ashworth Scales.

STUDY DESIGN

A theoretical analysis following a structured literature review (key words: Ashworth; Spasticity; Measurement) of 40 papers selected from the BIDS-EMBASE, First Search and Medline databases.

CONCLUSIONS

The application of both scales would suggest that confusion exists on their characteristics and limitations as measures of spasticity. Resistance to passive movement is a complex measure that will be influenced by many factors, only one of which could be spasticity. The Ashworth Scale (AS) can be used as an ordinal level measure of resistance to passive movement, but not spasticity. The modified Ashworth Scale (MAS) will need to be treated as a nominal level measure of resistance to passive movement until the ambiguity between the '1' and '1+' grades is resolved. The reliability of the scales is better in the upper limb. The AS may be more reliable than the MAS. There is a need to standardize methods to apply these scales in clinical practice and research.

Rehabilitation after traumatic brain injury

Head injury is a common disabling condition but regrettably facilities for rehabilitation are sparse. There is now increasing evidence of the efficacy of a comprehensive multidisciplinary rehabilitation team compared to natural recovery following brain injury. This chapter outlines some basic concepts of rehabilitation and emphasises the importance of valid and reliable outcome measures. The evidence of the efficacy of a rehabilitation programme is discussed in some detail. A number of specific rehabilitation problems are outlined including the management of spasticity, nutrition, pressure sores and urinary continence. The increasingly important role of assistive technology is illustrated, particularly in terms of communication aids and environmental control equipment. However, the major long-term difficulties after head injury focus around the cognitive, intellectual, behavioural and emotional problems. The complex management of these disorders is briefly addressed and the evidence of the efficacy of some techniques discussed. The importance of recognition of the vegetative stage and avoidance of misdiagnosis is emphasised. Finally, the important, but often neglected, area of employment rehabilitation is covered.

Traumatic brain injury: efficacy of multidisciplinary rehabilitation

OBJECTIVE

To establish efficacy of a coordinated multidisciplinary rehabilitation service for severe head injury, provided at Hunters Moor Regional Rehabilitation Centre.

DESIGN

A quasi-experimental design to compare treatment effects between two groups. The first group received a coordinated, multidisciplinary regional rehabilitation service; the other, a single discipline approach provided by local, district hospitals. Follow-up was for 2 years postinjury.

PATIENTS OR OTHER PARTICIPANTS

Fifty-six consecutive severe head injury admissions, with an identified main caregiver, referred for rehabilitation within 4 weeks of their injury.

MAIN OUTCOME MEASURES

The Barthel index, the Functional Independence Measure (FIM), and the Newcastle Independence Assessment Form (NIAF), a newly developed, real-life, comprehensive measure. In addition, caregivers completed the General Health Questionnaire.

RESULTS

The group that received coordinated multidisciplinary rehabilitation not only demonstrated significant gains throughout the study period but also maintained treatment effect after input ended. Furthermore, caregivers of this group had significantly reduced levels of distress. The comparison group, despite initial lower injury severity and shorter hospital stay, did not demonstrate equivalent gains or any posttreatment effect.

CONCLUSIONS

The results show the efficacy of a comprehensive, specialist multidisciplinary regional service. There are significant implications for service provision for people with severe traumatic head injury.

The further validation and precision of the NIAF-R

It is essential that any tool which is measuring outcome following head injury is sensitive to change over time. The Newcastle Independence Assessment Form-Research (NIAF-R) has been developed to be appropriate and applicable both in the acute situation and in the long-term. This paper illustrates the NIAF-R's level of sensitivity to change over time from eight weeks through to one year post-injury. There were no ceiling effects demonstrated at follow-up. Such effects can be a problem with other comparable measures. In addition, the results of further concurrent validation with the Barthel index, are reported. The NIAF-R scoring is refined through the development of an Adjusted Severity Indicator for more stringent analysis of level of independence. Scoring can now provide data in 55 individual areas of function for each subject or alternatively give an overall measure of severity of functional independence. Finally, this paper demonstrates the ability of the NIAF-R to predict outcome at follow-up.

Treating and nursing patients with multiple sclerosis

In this article, the author outlines the current treatments available for multiple sclerosis, and suggests that specialist nurses may play a valuable link role in the care of patients with a disease which remains incurable but not untreatable.

Outpatients in neurological rehabilitation

This paper discusses the experience of working within a multidisciplinary neurological clinic in a regional rehabilitation centre. The number and types of interventions are analysed which confirm the importance of having a wide range of rehabilitation professionals available in or attached to such clinics. The implications of these findings are discussed with regard to the range of professionals required and the study has produced evidence that would support the establishment of certain specific disability clinics, particularly spasticity, orthotic and memory clinics. The need for specific disease-orientated clinics, particularly for multiple sclerosis and head injuries, is also discussed. A questionnaire was sent to all new attenders at the Newcastle clinic seeking patient's views on the clinic format. There was general support for a multidisciplinary approach to outpatients and the majority of people felt that their needs had been properly addressed. However, a significant minority felt intimidated by a large number of professionals seen simultaneously and felt that their full range of problems had not been discussed. The patient's preference was for a drop-in clinic when they could attend without appointment to discuss a particular problems with the relevant professional. The least popular format was to be seen simultaneously by a range of different rehabilitation professionals.

Parkinson's disease: the spectrum of disabilities

The needs of people with Parkinson's disease (PD) go beyond the purely medical domain and often require collaborative management. A Panel Discussion at the "Hither neurology" Symposium included neurologists, a speech therapist, a geriatrician and a sociologist. Their discussion highlighted certain aspects of the disability and disadvantage associated with PD. The starting point was a video recording, "Parkinson's Disease: the personal view", in which the contributors were patients and carers. Topics covered included counselling at the time of diagnosis; subsequent access to clinics and to neurological advice; access to therapy; support in the community; fluctuating disability associated with "on-off" phenomena; driving; and sexual problems.

Human lactation: forearm trabecular bone loss, increased bone turnover, and renal conservation of calcium and inorganic phosphate with recovery of bone mass following weaning

The calcium (Ca) metabolism of established human lactation was studied in 40 adult women (mean age 32.4 years) who had been breast-feeding for 6 months (Lac) and in 40 age-matched controls (Con) using fasting urine and blood biochemistry and forearm single-photon bone mineral densitometry (BMD). Serial studies were performed up to 6 months after weaning in Lac women and repeated once in Con women. During lactation the significant findings were (1) a selective reduction (7.1%, P less than 0.03) in BMD at the ultradistal site containing 60% trabecular bone, but not at two more proximal, chiefly cortical bone sites; (2) increased bone turnover affecting bone resorption [fasting hydroxyproline excretion, Lac 2.22 +/- 0.12 mumol/liter GF (mean +/- SEM), Con 1.19 +/- 0.04, P less than 0.001] and affecting bone formation (plasma alkaline phosphatase, Lac 81.9 +/- 2.5 IU/liter, Con 53.5 +/- 2.7, P less than 0.001, and serum osteocalcin, Lac 14.0 +/- 0.7 microgram/liter, Con 7.3 +/- 0.4, P less than 0.001); and (3) renal conservation in the fasting state of both Ca and inorganic phosphate (Pi) with a resultant moderate increase in plasma Pi but not in plasma Ca (total or ionized). There were no differences between the groups in serum parathyroid hormone (PTH, intact and midmolecule assays), 25-hydroxy- and 1,25-dihydroxyvitamin D, nephrogenous cyclic AMP production, or plasma creatinine.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultradistal and cortical forearm bone density in the assessment of postmenopausal bone loss and nonaxial fracture risk

Forearm bone mineral density (BMD) was measured by single-energy photon absorptiometry in 360 healthy females without known axial fractures, 202 of whom were postmenopausal. The three sites addressed included an ultradistal (U) region containing approximately 60% trabecular bone. The other sites, distal (D) and shaft (S), were progressively more cortical. Reproducibility was 1.7-1.9% CV. The earliest evidence of a significant correlation between BMD and years since menopause was seen in trabecular bone in subjects aged 45-55 years. Fractional decrease in BMD, relative to the premenopausal value, was significantly larger at U than at S for the decades 55-65 years and above. Fractional rates of bone loss at all sites were a maximum in the first postmenopausal decade, the rate at U being 0.035, approximately 1.5 times that at D or S. A total of 33 subjects reported 54 previous minimally traumatic nonaxial (MTNA) fractures. When BMD measurements of the entire study were divided into quintiles, the prevalence of MTNA fracture cases in the lowest quintile was eight times that of each of the upper three quintiles. Prevalence of fracture cases ranked by quintiles of BMD were not different for the three scan sites. Therefore, ultradistal measurements confer no advantages over distal or shaft BMD for discriminating past MTNA fracture cases but do show larger fractional rates of loss during the first postmenopausal decade.(ABSTRACT TRUNCATED AT 250 WORDS)

A rehabilitation ward in a district general hospital: first three years' experience

The experience of the first three years' work on a ward for the rehabilitation of patients was reviewed. Adults with physical disabilities or mixed physical and psychological disabilities, including unstable or deteriorating conditions, were accepted for intensive rehabilitation. Most patients had neurological disorders. The ward policy was that each patient had considerable time with the therapist, maximum personal independence was encouraged, and multidisciplinary staff meetings were held to agree the goals of treatment. Much effort was spent helping patients and relatives to adapt to conditions of progressive disability, but the response to questionnaires suggested that these patients as well as those who did improve received some benefit from being on the ward. Overall the benefits of the intensive rehabilitation that was offered on this ward outweighed those from short stays on medical wards.

Hyperbaric oxygen and multiple sclerosis: final results of a placebo-controlled, double-blind trial

The long term results are reported of a trial involving 120 patients with chronic multiple sclerosis who were randomised to receive either 100% oxygen at 2 atmospheres absolute (ATA) for 90 minutes daily for 20 sessions or placebo therapy with air using a simulated compression procedure. The previous finding of subjective improvement in bowel/bladder function at the end of treatment was not confirmed by objective urodynamic assessment. The treatment did not alter disease progression as measured by the Kurtzke disability status scale nor did it alter the rate of acute relapse. There was less deterioration in cerebellar function at one year in the treated patients as measured by the Kurtzke functional systems scale. No other differences were found between the two groups. Psychometric tests and measurements of lymphocyte sub-populations showed no treatment related effects. Evoked potential studies showed no improvements but there was a significant reduction in amplitude of the visual evoked potential in the treated patients at the end of therapy. This might indicate a reversible degree of retinal damage induced by oxygen toxicity.

The syndrome of Karl Ludwig Kahlbaum

Karl Ludwig Kahlbaum was the first to describe catatonia in 1868. There has been a tendency to consider catatonia as a psychiatric disease despite many case reports demonstrating a wide range of medical and neurological as well as psychiatric causes. We present our accumulated experience of the catatonic syndrome. Most cases (36%) were associated with affective illness but five cases (20%) had a defined organic disorder. A significant minority had no identifiable cause and there was only one case of schizophrenia. The idiopathic and affective groups had a high incidence of recurrent catatonic episodes and many had a family history of a similar problem. The prognosis was excellent, except for the few patients who presented with the acute and rapidly progressive form of the syndrome which led to acute renal failure.

Delayed encephalopathy following cardiac arrest

A 46 year old woman suffered a post-operative cardiac arrest associated with prolonged depression of oxygenation and respiration. She made a good initial recovery but one year later insidiously developed symptoms of widespread central nervous system damage compatible with a delayed post-hypoxic encephalopathy. This case is unusual in the length of time between the hypoxic insult and the later deterioration and also illustrates other atypical features of a delayed post-hypoxic syndrome.

Hyperbaric oxygen and multiple sclerosis: short-term results of a placebo-controlled, double-blind trial

In a study of 120 patients with chronic multiple sclerosis the effects of treatment with 100% oxygen at 2 atmospheres absolute for 90 min daily for a total of 20 exposures were compared with those of normal air at normal pressure for a similar length of time within the same compression chamber. No patient in either group showed any improvement on the Kurtzke disability status scale. 12 of 51 patients in the hyperbaric-oxygen group and 3 of 47 control patients improved on the Kurtzke functional systems scale on the subjective bowel/bladder parameter only. Such a degree of improvement can also be achieved with medication for urinary symptoms, but none of the patients in this study received such medication. The short-term results of this trial do not support the claims made for hyperbaric oxygen in the management of multiple sclerosis.

Intravenous methylprednisolone for multiple sclerosis in relapse

A randomised comparison is made between methylprednisolone, 1 g intravenously daily for 7 days, and a standard ACTH regime for the treatment of multiple sclerosis in acute relapse. It is found that methylprednisolone produces a more rapid clinical improvement than ACTH but confers no longer term benefit when the two treatments are compared at 3 months. It is proposed that intravenous methylprednisolone does have a role to play in the management of a patient with an acute relapse of multiple sclerosis.