Neurorehabilitation and Neural Repair

Background and Purpose: To test whether multidisciplinary rehabilitation (MDR) is effective in improving functional outcome in chronic stroke.

Methods: Retrospective review of functional outcome of MDR in 136 consecu tive patients with first single stroke. Patients were divided into early group (E: days after stroke ( 90, n = 47) and late group (L: > 90, n = 89). Outcome was assessed by using the Functional Independence Measure (FIM) and the Stroke Impairment As sessment Set (SIAS).

Results: Both groups were comparable in terms of age, gender, type of stroke, and side of stroke. The mean length of stay was significantly longer (p < 0.05) in E (138 days) than in L (114 days). The mean FIM (admission/discharge) was 88/103 in E and 88/97 in L. The mean SIAS was 11/14 in E and 10/13 in L. There was no signif icant difference in gain of FIM and SIAS score between the groups. There was also no difference in gain of FIM between E and L in three subgroups based on admission FIM score (severe disability: 18-53, moderate: 54-89, mild: 90-126).

Conclusions: MDR is effective in improving functional outcome of stroke patients regardless of starting point of MDR or initial severity of disability. Key Words: Stroke—Rehabilitation—Functional Independence Measure (FIM)—Stroke Impair ment Assessment Set (SIAS).

Given the importance of the sense of smell and the many possible reasons for its im pairment in patients with spinal cord injury, we performed a study to determine the status of olfactory senses among 28 men (22 to 82 years of age) who had been afflicted with spinal cord injury for 2 years. Lesions were complete in 29 percent; 71 percent had tetraplegia. Each subject was interviewed to determine chemosensory risk factors and then given two standard tests of olfaction: the University of Pennsylvania Smell Identification Test (UPSIT) and the Chicago Smell Test (CST). On the former, nor malized for age and gender, 26 patients (93 percent) were hyposmic and on the latter, 11 (39 percent) were hyposmic. These data reflect a high incidence of olfactory dys function. Analyzed statistically, this impairment was found to be unrelated to smok ing, alcohol or drug use, medications, or level of completeness of the spinal cord le sion. Routine testing for olfactory dysfunction among patients with spinal cord injury, whether or not they have a history of head trauma, deserves consideration. The man agement of patients with smell loss should be modified to maintain their nutritional status and safety. Key Words: Chronic spinal cord injury—Olfaction.

We present the first case of deterioration of aphasia associated with a nondominant (right) hemisphere lesion in an area that is nonhomotopic to left hemisphere language zones. A 70-year-old right-handed woman, who had partially recovered from Wer nicke's aphasia after a left posterior temporal and occipital lobe ischemic infarct, pre sented with sudden deterioration of aphasia. Imaging studies of the brain showed a new intraparenchymal hemorrhage in the right occipital lobe. Speech evaluation demonstrated worsening of comprehension, repetition, writing, and verbal expression. During a 4-month follow-up period, a small improvement in the ability to repeat was made, but no gains in functional language skills were achieved. This study provides evidence for participation of the right hemisphere in recovery from aphasia after left hemisphere damage. It also suggests that the subsequent lesions in the right hemi sphere cortex may not necessarily have to be located within an area that is homotopic to left hemisphere cortical language zones. The possible mechanisms for this deteri oration include diaschisis, disruption of interhemispheric fibers descending from the cortical parieto-temporo-occipital junction area, and synergistic effects. Key Words: Language—Recovery—Right hemisphere—Occipital lobe—Homotopic areas.

Chronic neuromuscular impairments contribute to functional disability following stroke. Despite the widely held notion that only limited gains in motor performance are possible beyond the initial subacute stroke recovery period, we tested the hy pothesis that a "task-oriented" aerobic treadmill training program would improve lower extremity muscle strength and alter spastic reflexes in chronic hemiparetic patients. Fourteen subjects, aged 66 ± 3 (mean ± SEM) years, with mild to moderate hemi paresis and gait deviations due to remote stroke (>6 months) were entered in a pro gram of low intensity aerobic exercise (AEX) three times a week. Repeated measures of volitional (eccentric and concentric) and reflexive (spastic) torque generated by the quadriceps muscles were performed bilaterally using isokinetic dynamometry at four angular velocities (30°, 60°, 90°, and 120°/sec) before and after 3 months of AEX. Regular exercise training increased mean eccentric torque production significantly across all angular velocities in the more affected (51 percent) and less affected (25 percent) limbs. Similarly, concentric torque output increased in the more paretic and less paretic quadriceps by 38 percent and 17 percent, respectively. Reflexive torque gen eration was unchanged statistically. The greatest relative strength gains were seen in the more affected limb at higher eccentric angular velocities and at lower concentric velocities. These findings demonstrate that treadmill AEX training improves leg strength, which may in turn improve functional mobility in subjects with chronic hemi paresis. Key Words: Stroke rehabilitation—Aerobic exercise—Treadmill training— Isokinetic dynamometry.

Objectives: A pilot study was conducted on five patients with an incomplete spinal cord injury (iSCI) using a body weight support treadmill training (BWSTT) gait strat egy within the subacute phase of recovery. The objectives of this project were to de fine appropriate candidates, identify treatment parameters, select impairment and dis ability outcome measures, and solicit consumer input in preparation for a clinical efficacy trial.

Methods: Five patients with injuries ranging from C2 lesion to T10 lesion con sented to participate and were within 2 months post injury. A commercially available mechanical suspension frame straddled a motorized treadmill, and a modified climber's harness was used for support. All participants were nonambulatory on entry into the study. The BWSTT intervention, consisting of 36 1-hour sessions over a 3-month period, was conducted by physical therapists and was customized to the patient's abil ities. Evaluations were conducted at baseline, at 6 weeks, and at the 12-week post- test interval. Clinical impairment measures included muscle strength, sensation, mus cle tone, perceived exertion, and treadmill training endurance. Gait analysis provided dynamic quantification of kinematic and surface electromyography (EMG) of five mus cles of the right lower limb on all participants on the BWS treadmill and three of the five patients during overground walking. A disability outcome measure was used to grade the level of ambulation function. A consumer team member conducted feed back interviews with participants to obtain their input to this research direction.

Results: Lower limb unloading varied from 26 percent to 83 percent of body weight. All participants completed the 12-week training program and four individu als eventually progressed to overground walking. The fifth participant, who had the most severe motor impairments, did not achieve functional overground walking with out the aid of bilateral knee-ankle-foot orthoses. Improvements were evident in the clinical measures of strength, endurance, and percent BWS in four patients. Positive changes were recorded in temporal-spatial, joint motion, and EMG gait measures matching increased ambulation function in four of the five patients. Gait analysis

changes in one patient were highlighted to illustrate dynamic measures of motor re covery. Consumer input and feedback from patients and therapists were positive and included suggestions for improvements.

Conclusions: A multicenter randomized controlled trial is advocated to evaluate the efficacy of a BWSTT gait strategy in the subacute recovery phase of iSCI. This pilot work resulted in specific recommendations in the selection of candidates, the training and evaluation parameters, and the potential value of consumer input for fu ture research. Key Words: Incomplete spinal cord injury—Rehabilitation—Weight- supported treadmill gait training—Consumer input.

Despite advances in treatment, the availability of assistive technology, and passage of the Americans with Disabilities Act (ADA), unemployment is a significant problem for people with multiple sclerosis (MS). Some researchers have attributed this prob lem to personal factors, including fatigue or other impairments caused by MS or lack of education and training. Other writers focus on societal barriers, including negative public attitudes or lack of physical access. This article uses qualitative methods to ex plore another hypothesis: policies contained within federal programs themselves, such as income maintenance, health care, and vocational rehabilitation, constitute a third set of barriers to employment for people with MS. Key Words: Multiple sclerosis— Employment—Social Security Disability—Vocational rehabilitation—Health care.