Internal and External Focus of Attention During Gait Re-Education: An Observational Study of Physical Therapist Practice in Stroke Rehabilitation.

Internal and External Focus of Attention During Gait Re-Education: An Observational Study of Physical Therapist Practice in Stroke Rehabilitation.

Phys Ther. 2013 Apr 4;
Johnson L, Burridge JH, Demain SH

BACKGROUND: focus of attention is known to play an important role in motor skill learning, yet little is known about how attention is directed within the context of stroke rehabilitation OBJECTIVE: to identify physical therapists use of internal and external focus of attention during gait rehabilitation for individuals with hemiplegia following stroke; and to use the findings to design an experimental study examining the impact of focus of attention on learning post stroke. DESIGN: direct non-participation observation of physical therapy treatment sessions. METHODS: 8 physical therapy treatment sessions, in which gait rehabilitation was taking place, were video recorded. Patients were aged between 36 and 85 years, and ranged from 7 to 216 days post stroke; physical therapists had between 3 and 12 years experience within stroke rehabilitation. Data analysis took two forms: a) clear definitions of internal and external focus of attention were agreed via a consensus group, and used to develop an analysis matrix through which incidences of instruction and feedback were identified, categorised and counted; and b) verbal dialogue was transcribed verbatim and transcripts were thematically analysed to provide a detailed description of how instructions and feedback were used, illustrated by examples. RESULTS: the use of instructions and feedback (internal and external focus) was high; an average of one verbal instruction or feedback statement was delivered every 14 seconds. 67% of statements were internally focussed, 22% were externally focussed, and 11% mixed focus. Unfocussed statements (e.g. “good”) were also used regularly. Patients were frequently encouraged to “think about” their performance. CONCLUSION: physical therapists frequently encouraged patients to be aware of their movements and their performance (internal focus). This approach may reduce automaticity and hinder learning and retention. HubMed – rehab

Psychometric Properties of the Mini-Balance Evaluation Systems Test (Mini-BESTest) in Community-Dwelling Individuals With Chronic Stroke.

Phys Ther. 2013 Apr 4;
Tsang CS, Liao LR, Chung RC, Pang MY

BACKGROUND: The Mini-Balance Evaluation Systems Test (Mini-BESTest) is a new balance assessment but its psychometric properties have not been specifically tested in individuals with stroke. OBJECTIVES: To examine the reliability and validity of the Mini-BESTest, and its accuracy to categorize participants based on fall history among people with stroke. DESIGN: Observational measurement study with a test-retest design. METHODS: One-hundred-six people with chronic stroke were recruited. Intra-rater reliability was evaluated by repeating the Mini-BESTest within 10 days by the same rater. The Mini-BESTest was administered by two independent raters to establish inter-rater reliability. Validity was assessed by correlating Mini-BESTest with other balance measures (Berg balance scale (BBS), one-leg-standing, functional reach, Timed-Up-and-Go) in the stroke group, comparing the Mini-BESTest scores between the stroke group and 48 control participants, and also between fallers (?1 falls in the past 12 months, n=25) and non-fallers (n=81) in the stroke group. RESULTS: The Mini-BESTest had excellent internal consistency (Cronbach’s alpha=0.89-0.94), intra-rater reliability (ICC3,1=0.97) and inter-rater reliability (ICC2,1=0.96). The minimal detectable change at 95% confidence interval was 3.0 points. The Mini-BESTest was strongly correlated with other balance measures (p?.001). Significant difference in Mini-BESTest total score was found between the stroke and control groups (p?.001), and also between fallers and non-fallers in the stroke group (p=0.03). In terms of floor/ceiling effects, the Mini-BESTest was significantly less skewed than other balance measures (p?.001), except one-leg-standing on the non-paretic side (p=0.965). The BBS showed significantly better ability to identify fallers than the Mini-BESTest (p=0.01). LIMITATIONS: The results are only generalizable to people with mild to moderate chronic stroke. CONCLUSIONS: The Mini-BESTest is a reliable and valid tool for evaluating balance in people with chronic stroke. HubMed – rehab

[Posterior reversible encephalopathy as the first manifestation of Guillain-Barré syndrome. Report of one case].

Rev Med Chil. 2012 Oct; 140(10): 1316-20
Urrutia L S, Venegas R E, Figueroa V C, Carrizo C C

Background: We report a 56year old male hypertensive, who presented with a posterior reversible encephalopathy syndrome (PRES) as an initial manifestation of Guillain-Barré syndrome (GBS). His first symptoms were right hemiparesis and hemihypoesthesia, followed by headache, dizziness, dysarthria and a general feeling of discomfort. On the third day, flaccid tetraparesis, impairment of consciousness, epileptic seizures and respiratory failure appeared, along with severe hypertension. Cerebral Magnetic Resonance Imaging showed the characteristic PRES lesions. Cerebrospinal fluid analyses revealed albumin-cytological dissociation and nerve conduction studies showed an axonal demyelinating polyradiculoneuropathy, which confirmed the diagnosis of GBS. Treatment with intravenous immunoglobulin was given together with antihypertensive therapy and mechanical ventilation, achieving an important clinical and imaging remission of PRES, but maintaining tetraparesis during the hospitalization. Twelve months after discharge and regular motor rehabilitation, the patient achieved complete autonomy on the activities of daily living. It has been postulated that the autonomic failure and the elevation of circulating pro-inflammatory cytokines in GBS may be the cause of a breach in the blood-brain barrier, thus causing PRES, that can completely remit with an adequate management. HubMed – rehab

West nile virus infection and myasthenia gravis.

Muscle Nerve. 2013 Apr 5;
Leis AA, Szatmary G, Ross MA, Stokic DS

Introduction: Viruses are commonly cited as triggers for autoimmune disease. It is unclear if West Nile virus (WNV) initiates autoimmunity. Methods: We describe 6 cases of myasthenia gravis (MG) that developed several months after WNV infection. All patients had serologically confirmed WNV neuroinvasive disease. None had evidence of MG prior to WNV. Results: All patients had stable neurological deficits when they developed new symptoms of MG 3-to-7 months after WNV infection. However, residual deficits from WNV confounded or delayed MG diagnosis. All patients had elevated acetylcholine receptor (Ach-R) antibodies, and 1 had thymoma. Treatment varied, but 4 patients required acetylcholinesterase inhibitors, multiple immunosuppressive drugs, and intravenous immune globulin (IVIG) or plasmapheresis for recurrent MG crises. Discussion: The pathogenic mechanism of MG following WNV remains uncertain. We hypothesize that WNV-triggered autoimmunity breaks immunological self-tolerance to initiate MG, possibly through molecular mimicry between virus antigens and Ach-R subunits or other autoimmune mechanisms. © 2013 Wiley Periodicals, Inc. HubMed – rehab