Archive for March, 2017
My dad had his first seizure when I was 10 years old. I remember being confused by his reaction to his developing epilepsy, and my family members felt the same way. He seemed to want to ignore what had happened, and he seemed to be in a mixture of complete denial while also being aware of it and just not caring enough or wanting to be careful enough. I was terrified for him. He lived alone, and I knew that his risk of having a seizure without anyone realizing it was quite high. I hated that he wanted to blow off doctors appointments or to not follow-up on test results.
I had my first epileptic seizure last October, at age 23. You can read about my first seizure and my second seizure in my past blog posts if you’d like. Prior to my first seizure, if someone would have asked how I would respond if I were to have a seizure out of the blue, my answer would have been simple: PANIC. I’m prone to anxiety about small, trivial matters. I would have guessed that I would be terrified about my health, and that I would want to have as much testing as possible to get answers as quickly as possible. I would have guessed that I would be completely on top of my medication and avoiding risky behaviors such as drinking or not getting enough sleep (alcohol and sleep deprivation both lower the seizure threshold). I would have guessed that I wouldn’t hesitate to accept the reality of my situation, and that if I found a medication that prevented my seizures, that I would be terrified to get off that medication even years later.
Yet, my real reaction to my seizures has been quite different. It’s now been about 8 months since I had the seizures and I’ve experienced a roller coaster of emotions, several of them I’ve experienced several times over. Fear or panic has not been my primary reaction like I would have expected. I think my friends and family members have probably been a bit surprised by my reaction. I realize that there are probably a lot of friends or family members of people with seizures and/or epilepsy who are struggling to understand why their seizure-prone loved one isn’t reacting the same way that they are. My goal for this blog post is to share the roller coaster of emotions that I have experienced and why. I’m going to run in the order that the emotions showed up for me.
Confusion. When I first “came to” after my seizure my first reaction was confusion. I felt like I had been sleeping for HOURS and was waking up mid-dream. So, it was confusion but not a logical, well thought out confusion but instead just a really surface level “hmm that seems odd” type confusion.
(emotional) numbness: Once I was at the hospital, I remember realizing that others (Ryan, my mom, etc) were quite worried about me. Everyone seemed serious and concerned. This was mildly confusing to me because I was still in a “foggy” mental state and the reality of what had happened hadn’t hit me yet.
Exhaustion: Despite having felt like I had been asleep for hours when I first “came to”, I was still exhausted afterwards. I did a LOT of sleeping and when I would wake up I still felt tired.
Frustration: I was hospitalized for five or six days after my second seizure and on about day three of being in the hospital I became frustrated. I was tired of being poked, prodded and of just being in the hospital in general. I was frustrated that I had so many people concerned about me because I just wanted to sleep and have time to myself to absorb what had happened and to wrap my mind around it.
Denial: After getting out of the hospital, I googled seizures and read that most of the time, doctors don’t medicate people after a single seizure because their odds of having a second seizure are fairly low (under 50%). If a person has 2 seizures within 2 year,s their odds of having a third seizure are more likely than not (over 50%) so after a second seizure medication usually is started. After being out of the hospital for a little bit I remember saying to my boyfriend “I guess I should try to accept that I ‘just’ have epilepsy. That maybe my brain just had a seizure for no apparent reason and we won’t find a cause and my brain just needs anti-epileptic medication to avoid seizing now.” I meant to suggest this as a ‘worst case scenario’ that I should try to mentally prepare for. Yet as soon as I said it, I realized by the look on his face that my boyfriend believed that to be true already. He had already accepted that my seizures weren’t just “random” and that something in my brain had changed. I was still assuming that we would find some weird answer such as an infection or illness (even though all of my testing came back normal and I had no symptoms of illness prior to, during or after the seizures). I was in denial.
Sadness. Once I realized that I didn’t have a seizure as a result of any illness, infection or other “random” cause, it started to sink in that we probably wouldn’t get answers to what had happened, and I was probably at a high risk of having more seizures if I weren’t on medication. This was hard for me to swallow and caused sadness.
Hopelessness. I was 23, childless and had been with my boyfriend for 7 years when I had my first seizure. After accepting that I was probably now dependent on seizure medication to avoid seizures, I realized that this was an important factor regarding getting pregnant, being pregnant and giving birth. Even the safest of seizure medications increase the risk of birth defects, even though the risk is fairly low (my neurologist said about 8% vs the general population being at about a 2% risk for birth defects). I also began to realize that with my father having epilepsy, and now me having seizures myself that perhaps this is somehow genetic and if I do have a healthy pregnancy and birth, I could pass the epilepsy on to my child. This is the hardest for me to handle because I love children and have always dreamed of being a mother someday. At first, I was fixated on the thought that if I have a baby while on seizure medication and then my baby has a birth defect, or I miscarry, or my child has epilepsy I would forever feel guilty. If any of those things happened, would I live in regret feeling selfish for having chosen to go ahead with having a baby knowing my risks? If that IS selfish, then isn’t the obvious unselfish thing to do be to not have children? Not having children has never really felt like an option for me. So for a while I became overwhelmed with helplessness.
Determination. After feeling hopeless for a while I realized how much I had to be thankful for. I was seizure-free since beginning medication. I have read stories of people who have completely uncontrolled seizures and I can’t even imagine how difficult that must be. I felt terrible for feeling all of these negative emotions regarding my situation when SO many others have it much, much worse. I realized that I needed to force myself to be determined to live with my seizures/epilepsy regardless of how many seizures I have or how it affects my life. Having children has been a dream of mine longer than anything else, and I realized I can’t let epilepsy take that from me no matter what.
Avoidance. It took me roughly 3 months to really wrap my mind around what had happened to me. I have always been a bit slow to accept change or big events. I have to repeat things in my mind over and over before I can find peace with them. Having seizures turned my world upside down and it took me a full three months to pick everything back up and put it back in place. During that three-month period, I was really up and down with my thoughts and feelings surrounding what had happened. I live in a small town so it’s hard to go into any store or business without seeing someone I know. My family members had posted on Facebook about my seizures (I did not) so it seemed like everyone knew what had happened. I ran into the grocery store and the bank and would be stopped by people who I only see a few times a year asking me details about what had happened. I was still trying to make sense of it myself, so I didn’t really have the ability to explain it all to other people. Sometimes I didn’t want to think about it at all, but even when I wasn’t avoiding thinking about it, I didn’t have an interest in re-hashing the details with people I am not emotionally close to. So I wanted to avoid most of the people I knew.
Loneliness. While I avoided going out in public too much to avoid having to talk about what happened, I found that this made me lonely. I needed more social interaction than I was getting, but I was afraid that venturing out into the world more would mean I had to address what happened, so I felt stuck between a rock and a hard place.
Anxiety. Both of my seizures happened at night, within an hour of falling asleep. For months (five or so?) I don’t think I laid down for bed a single time without the thought of “what if I have a seizure in 20 minutes?” crossing my mind. This made it really hard to fall asleep , and then I would start thinking about how NOT sleeping increased my odds of having a seizure (sleep deprivation) which increased my anxiety and the cycle just kept going. A few nights I would lay in bed for over 3 hours before finally falling asleep. I also experienced anxiety when going out with my mom or my sister when my boyfriend would stay home. I knew that he handled my seizures perfectly (calling 9-1-1) but I have never really seen most other people respond to a seizure so I’m not sure if they would freeze or panic or if they’d get me help. I was particularly anxious about going with my sister because her children were only 1 and 4 and I was afraid of having a seizure in front of them as that would be traumatic for them.
Panic. Every once in a while I’d have a new “symptom” that I had never experienced before and I would panic, thinking that it might be an aura. I had read that many people with epilepsy have auras that include things like “floaters” in their vision, the smell of burning rubber, a smell of gunpowder, a metallic taste in their mouth, sudden confusion/brain fog, etc. Our apartment had a radiator style electric heater that ran along the base of our living room wall. Once a pair of waterproof gloves fell onto the heater and started to melt, and my heart started beating so quickly and I blurted out “I smell something burning! Do you smell something burning?!” and to my horror my boyfriend said no, he didn’t smell anything. I felt like I could barely breathe and my chest was tight because I was so panicked. Thankfully, my boyfriend got up and walked around and then said “Oh yeah I do smell it over here” and then found the glove so I realized it was a ‘real’ smell and not an aura.
More denial and avoidance. The last few months (5-8 months post-seizures) my primary emotions have been denial and avoidance. I feel exactly like I did before having seizures. I’ve accepted that the odds of any kind of test showing a cause for my seizures is highly unlikely. So, when it comes to making appointments at my neurologists or scheduling testing that my doctor or neurologist wants me to have, I tend to just want to avoid going. I don’t feel like the odds of the test showing anything are very high, I hate how going through with the testing makes me recall what happened, and I just don’t enjoy being at the doctors or having testing done in general. Logically I know that it makes sense to do whatever testing and appointments my neurologist feels are worthwhile, but it’s emotionally easier for me to avoid appointments and tests and just avoid having to think about seizures or epilepsy at all.
If you have had seizures, please feel free to share what emotions you’ve dealt with in the comments. Or, if you love someone with epilepsy feel free to share your emotions about the situation as well. The goal of this blog post is to increase awareness of what emotions may come along with seizures and an epilepsy diagnosis, but I’m only one person so I’m sure others out there have different experiences and emotions.
I also want to apologize if this came across as whiny or ungrateful for how lucky I have been to have seizure control while on medication, and to have very few side effects from medication. I realize that my situation could be much worse than it is, and I’m somewhat ashamed of the emotions that I’ve felt in the past (primarily hopelessness and sadness because others have it so much worse) but I wanted to be as honest as possible about my experience. My goal isn’t to whine or complain or get sympathy at all, I just want others to realize they aren’t alone and their emotions post-seizure and/or epilepsy diagnosis are normal.
[Abstract+References] Movement Kinematics of the Ipsilesional Upper Extremity in Persons With Moderate or Mild Stroke
Background. An increasing number of studies have indicated that the ipsilesional arm may be impaired after stroke. There is, however, a lack of knowledge whether ipsilesional deficits influence movement performance during purposeful daily tasks.
Objective. The aim of this study was to investigate whether, and to what extent, movement impairments are present while performing an ipsilesional upper extremity task during the first 3 months after stroke.
Methods. Movement kinematics describing movement time, smoothness, velocity, strategy, and pattern were captured during a standardized drinking task in 40 persons with first-ever stroke and 20 controls. Kinematics were measured early and at 3 months poststroke, and sensorimotor impairment was assessed with Fugl-Meyer Assessment in stroke.
Results. Half of the ipsilesional kinematics showed significant deficits early after stroke compared to controls, and the stroke severity had a significant impact on the kinematics. Movements of the ipsilesional arm were slower, less smooth, demonstrated prolonged relative time in deceleration, and increased arm abduction during drinking. Kinematics improved over time and reached a level comparable with controls at 3 months, except for angular velocity of the elbow and deceleration time in reaching for those with more severe motor impairment.
Conclusions. This study demonstrates that movements of the ipsilesional arm, during a purposeful daily task, are impaired after stroke. These deficits are more prominent early after stroke and when the motor impairment is more severe. In clinical studies and praxis, the use of less-affected arm as a reference may underestimate the level of impairment and extent of recovery.
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[ARTICLE] Effectiveness of a structured sexual rehabilitation programme following stroke: A randomized controlled trial – Full Text
Background: Sexual activity is an integral part of life; it is important to address sexual health after stroke, but this is often poorly done.
Objective: To assess the effectiveness of a structured sexual rehabilitation programme compared with written information alone regarding sexual and psychological functioning (anxiety, depression, stress), functional independence and quality of life in an Australian stroke cohort.
Methods: A total of 68 participants were randomized to a structured sexual rehabilitation programme (treatment group; n = 35) or to written information alone (control group; n = 33). Outcome measures included: Sexual Functioning Questionnaire Short Form; Depression, Anxiety Stress Scale; Functional Independence Measure, and Stroke and Aphasia Quality of Life Scale-39 Generic. Assessments were performed at baseline, 6 weeks and 6 months after the intervention. Participant’s preferences regarding how they would like to receive information, who from, and how frequently, were collected at baseline.
Results: There was no difference between groups for any outcome measures. Half of the participants (51%) wished to receive information and were divided equally into preferring written information vs face-to-face counselling, with the majority (54%) preferring information after discharge from an inpatient setting.
Conclusion: Provision of written information alone appears to be as effective as a 30-min individualized sexual rehabilitation programme in an inpatient setting. Further research is needed regarding longer term outcomes and outpatient settings.
Stroke is a leading cause of death and disability (1). Sexual dysfunction is common after stroke, and has multifactorial causes: damage to the brain (causing decline in sexual desire/interest and coital frequency for both sexes, decline in vaginal lubrication and orgasm in females, and in erection and ejaculation in males, and physical changes, such as hemiplegia with resulting impairment of mobility) together with medical issues, such as medications and premorbid medical conditions (diabetes, hypertension, cardiac issues) and psychological factors (fear of new stroke, loss of self-esteem, role/relationship changes) are major contributors (2–5).
Sexuality is a broad concept and may be experienced and expressed in a variety of ways; including thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles, and relationships (6). Sexual activity is an integral part of life and the importance of addressing sexual health after stroke is well accepted (7). Despite this, it is common for sexuality to be poorly addressed, not just in stroke, but also in other neurological conditions, such as spina bifida (8) and spinal cord injury (9). The 2012 Australian National Stroke Audit Rehabilitation Services Report (10), which included 2,789 post-stroke patients across 111 Australian public and private hospitals, showed that only 17% of patients received information on sexuality. This is despite the opportunities provided through the staffing complement in rehabilitation settings. In practice, allied healthcare providers could have a primary or secondary role in sexual rehabilitation; they could be the sole providers of intervention or provide further intervention in their specific areas of expertise, such as physiotherapy training to optimize mobility in bed for sexual positioning, nursing education for catheter management, and dyspraxia training with speech therapy for sexual activities such as kissing. In addition, although current guidelines recommend the assessment and management of post-stroke sexual dysfunction (7), it is unclear what types of intervention (timing, content, intensity, setting) should be provided and how effective they are. The only intervention study currently available in the literature that addresses the impact of intervention on sexual activity following stroke suggests that a sexual rehabilitation intervention programme prior to hospital discharge increased sexual satisfaction and frequency of sexual activity one month post-discharge, but did not promote sexual knowledge (11). This study was conducted with culturally homogenous 40–49-year-old Korean couples and had significant methodological limitations (generalizability, pre-post design, and short follow-up). Patient’s preferences relating to sexual counselling, such as the timing of such counselling, also varied, creating further challenges for optimization of care (12, 13). Some studies show that most participants feel overwhelmed in the early adjustment period and that the best time to address sexual adjustment issues is towards the end of an acute rehabilitation hospitalization or shortly after discharge. In a pilot randomized controlled trial (RCT) conducted in 2014, the feasibility and importance of providing sexual rehabilitation following stroke was demonstrated; however, the “pilot” nature of the study did not allow for conclusive findings to be drawn (14).
The primary aim of this RCT was to assess the effectiveness of a comprehensive structured sexual rehabilitation programme compared with written information alone, on sexual and psychological (anxiety, depression, stress) function, and on functional independence and quality of life in an Australian stroke cohort. Building on the previous pilot RCT, to our knowledge this will be the first adequately powered RCT in this area. The findings will provide evidence that may lead to improved care.
Objectives: More than 50% of human cerebral activity is related to vision. Visual impairments are therefore common after acquired brain injury, although they are often overlooked. In order to evaluate the prevalence of visual deficits in our Out-patient Brain Injury Program, a structured screening questionnaire, the Visual Interview, was administered.
Methods: A total of 170 patients with acquired brain injury, mean age 47 years, who were enrolled in the programme during 2010–12, underwent the Visual Interview. The interview consists of 18 questions concerning visual impairment and was performed on admission. The different types of visual impairment were compared with regard to sex and diagnosis.
Results: Fifty-four percent of the patients reported visual changes, mainly reading difficulties, photosensitivity, blurred vision and disorders of the visual field. Sixteen patients who did not experience visual changes also reported visual symptoms in 4–9 questions. Only slight differences were noted in the occurrence of visual symptoms when correlated with sex or diagnosis.
Conclusion: Visual impairments are common after acquired brain injury, but some patients do not define their problems as vision-related. A structured questionnaire, covering the most common visual symptoms, is helpful for the rehabilitation team to facilitate assessment of visual changes.
The visual system is widely distributed in the brain. It is integrated in more than 50% of human cerebral activity and is fundamental for interpretation of, and interaction with, the environment (1, 2).
A pyramidal hierarchical model of visual perceptual function was presented by Warren in 1993 (3). In this model, visual cognition forms the top level, followed by, in descending order: visual memory, pattern recognition, scanning, attention and a base level holding acuity, visual fields, and ocular motor control. The model illustrates how higher visual skills evolve from integration and interaction with lower skills and how visual cognition depends on well-functioning lower levels of visual perception.
Base level disturbances, such as visual field defects (VFDs), visual acuity changes, diplopia, strabismus, photophobia and different types of binocular disorders, are common after acquired brain injury (ABI) (4, 5), and lead to chronic headache, fatigue, dizziness, reading problems, and difficulties navigating the environment (6, 7). Although a complete VFD or manifest diplopia seldom escapes notice, disturbances of ocular motor abilities and photophobia are likely to be overlooked. Examinations of convergence and accommodation are not customary in standard ophthalmological assessments. Ordinary short examinations are unable to reveal declining attention ability and fatigue. Thus, the true problems may remain hidden.
Several reports of prevalence and quality of visual deficits after ABI document visual dysfunctions in approximately 50–75% of patients (8–13). The occurrence of different visual symptoms differs between the studies, including reading disturbances, VFD, diplopia, ocular motor dysfunction and photophobia. Nevertheless, visual symptoms are often overlooked in neurorehabilitation. The observations of Sand et al. (14) are noteworthy, i.e. that 1 of 4 stroke patients with VFD, 6 months after onset of stroke, considered that their visual problems reduced quality of life and increased their disability.
Visual disturbances after ABI are common and lead to reduced quality of life. An important question is why they are so often overlooked in neurorehabilitation? A possible explanation is the difficulty for different professionals to co-operate. Vision disturbances are complex and many different professionals operate in the field. An ability to co-operate is needed for a high-quality assessment. Another explanation could be the patients’ difficulty describing their shortcomings. They experience decreased reading speed, fatigue and dizziness, but do not recognize these problems as expressions of visual deficits. A structured questionnaire at admission would help the clinician to obtain informative answers.
In 1990, Kerkhoff et al (15). compiled an “Interview Questionnaire” in order to capture visual disorders after ABI. This interview was used by Wilhelmsen 2003 (12). Jacobsson & Hamelius translated it from Norwegian to Swedish in 2010 (16). During the last 5 years we have used this questionnaire, slightly modified, termed the Vision Interview (TVI), as an aid to discover visual deficits in our Out-patient Brain Injury Program.
The aim of the present study was to examine and analyse the occurrence of self-reported visual changes in a Swedish out-patient group with medium to severe ABI, based on TVI.
Saebo, Inc., is a leading global provider of innovative rehabilitation products for stroke survivors and other neurologically impaired individuals. Headquartered in Charlotte, NC, the company was founded in 2001 by two occupational therapists specializing in stroke rehabilitation. As the leading cause of long-term disability in the U.S., stroke affects over 700,000 Americans every year, leaving many with crippling side affects including the loss of hand function. Saebos pioneering treatment protocols are based on new research documenting the brains remarkable ability to re-program itself following injury.
The companys neurological orthotic devices, including the ground-breaking SaeboFlex and SaeboReach, allow patients with very little residual arm and hand function to immediately begin performing task-oriented, grasp and release activities, thereby forging new pathways in the brain. Named Most Valuable Product in 2008 by Therapy Times, the Saebo Program is now offered as a treatment option at over 2,000clinics and hospitals nationwide, including 22 of the Top 25 Rehabilitation Hospitals as ranked by U.S. News & World Report. The Saebo orthoses are also eligible for reimbursement by Medicare and most commercial insurers. With a network of over 6,000 trained clinicians spanning four continents, Saebo is committed to helping stroke survivors around the globe achieve a new level of independence.
Beginning with a twitch in his fingers about six months ago, a Canadian man has successfully re-animated his paralyzed hand after undergoing a nerve transfer surgery.
Tim Raglin regularly dove, headfirst, into the water at his family’s lake house. The 45-year old Canadian man had done so thousands of times without incident. In 2007, though Raglin hit his head on a rock in the shallow water, shattering a vertebra in his cervical spine.
His family pulled him to safety, saving him from drowning. However, for nine years, both his hands and feet were left paralyzed.
Now though, there’s hope for Raglin and others like him.
Raglin is the first Canadian to ever undergo a nerve transfer surgery. Dr. Kirsty Boyd from the Ottawa Hospital essentially rewired Raglin’s body– rerouting some of his fully-functional elbow nerves to his hand. Although Raglin had to wait several months for the nerves to regrow, this procedure allowed him to regain some control over his right hand.
ROAD TO INDEPENDENCE
After persevering for 18 months, Raglin was finally able to open his fingers during an occupational therapy session at The Ottawa Hospital Rehabilitation Centre.
“It was kind of a shock,” he said in an interview. “And it’s really moving now: There’s a lot of nerves touching muscles that are getting stronger…Every iteration, it just gets more and more exciting.”
It’s still a slow uphill battle for Raglin. The muscles in his hand have deteriorated from lack of use, so they tire easily. In addition, because Raglin is using a different nerve pathway to activate the muscles in his hand, it will take some time for his brain to adjust to the new system.
Despite these challenges, he has learned to close his fingers on something by flexing his bicep. In time, however, it’s expected his brain will figure out how to separate the triggers for his hand and his bicep.
“I’m not quite at the point where I can get a cup off the table, but I can envision myself doing that. I know I will be able to do that eventually—so it’s exciting to see that.”
- The neurophysiological effects of stroke are localised to the affected motor cortex.There is no clear evidence of imbalanced interhemispheric inhibition after stroke.Facilitating the affected motor cortex may be most beneficial in selected patients.
Transcranial magnetic stimulation (TMS) is commonly used to measure the effects of stroke on corticomotor excitability, intracortical function, and interhemispheric interactions. The interhemispheric inhibition model posits that recovery of motor function after stroke is linked to rebalancing of asymmetric interhemispheric inhibition and corticomotor excitability. This model forms the rationale for using neuromodulation techniques to suppress unaffected motor cortex excitability, and facilitate affected motor cortex excitability. However, the evidence base for using neuromodulation techniques to promote post-stroke motor recovery is inconclusive.
The aim of this meta-analysis was to compare measures of corticomotor excitability, intracortical function, and interhemispheric inhibition, between the affected and unaffected hemispheres of people with stroke, and measures made in healthy adults.
A literature search was conducted to identify studies that made TMS measures of the motor cortex in adult stroke patients. Two authors independently extracted data, and the quality of included studies was assessed. TMS measures were compared between the affected and unaffected hemispheres of stroke patients, between the affected hemisphere and healthy controls, and between the unaffected hemisphere and healthy controls. Analyses were carried out with data grouped according to the muscle from which responses were recorded, and separately according to time post-stroke (<3 months, and ≥6 months). Meta-analyses were carried out using a random effects model.
There were 844 studies identified, and 112 studies included in the meta-analysis. Results were very similar across muscle groups. Affected hemisphere M1 excitability is lower than unaffected and healthy control M1 excitability after stroke. Affected hemisphere short interval intracortical inhibition (SICI) is lower than unaffected and healthy control SICI early after stroke, and not different in the chronic phase. There were no differences detected between the unaffected hemisphere and healthy controls. There were only seven studies of interhemispheric inhibition that could be included, with no clear effects of hemisphere or time post-stroke.
The neurophysiological effects of stroke are primarily localised to the affected hemisphere, and there is no clear evidence for hyper-excitability of the unaffected hemisphere or imbalanced interhemispheric inhibition. This indicates that facilitating affected M1 excitability directly may be more beneficial than suppressing unaffected M1 excitability for promoting post-stroke recovery.
Researchers from Emory University have found that specific patterns of activity on brain scans may help clinicians identify whether psychotherapy or antidepressant medication is more likely to help individual patients recover from depression.
The study, called PReDICT, randomly assigned patients to 12 weeks of treatment with one of two antidepressant medications or with cognitive behavioral therapy (CBT). At the start of the study, patients underwent a functional MRI brain scan, which was then analyzed to see whether the outcome from CBT or medication depended on the state of the brain prior to starting treatment. The study results are published as two papers in the March 24 online issue of the American Journal of Psychiatry.
The MRI scans identified that the degree of functional connectivity between an important emotion processing center (the subcallosal cingulate cortex) and three other areas of the brain was associated with the treatment outcomes. Specifically, patients with positive connectivity between the brain regions were significantly more likely to achieve remission with CBT, whereas patients with negative or absent connectivity were more likely to remit with antidepressant medication.
“All depressions are not equal and like different types of cancer, different types of depression will require specific treatments. Using these scans, we may be able to match a patient to the treatment that is most likely to help them, while avoiding treatments unlikely to provide benefit,” says Helen Mayberg, MD, who led the imaging study. Mayberg is a Professor of Psychiatry, Neurology and Radiology and the Dorothy C. Fuqua Chair in Psychiatric Imaging and Therapeutics at Emory University School of Medicine.
Mayberg and co- investigators Boadie Dunlop, MD, Director of the Emory Mood and Anxiety Disorders Program, and W. Edward Craighead, PhD, J. Rex Fuqua Professor of Psychiatry and Behavioral Sciences, sought to develop methods for a more personalized approach to treating depression.
Current treatment guidelines for major depression recommend that a patient’s preference for psychotherapy or medication be considered in selecting the initial treatment approach. However, in the PReDICT study patients’ preferences were only weakly associated with outcomes; preferences predicted treatment drop-out but not improvement. These results are consistent with prior studies, suggesting that achieving personalized treatment for depressed patients will depend more on identifying specific biological characteristics in patients rather than relying on their symptoms or treatment preferences. The results from PReDICT suggest that brain scans may offer the best approach for personalizing treatment going forward.
In recruiting 344 patients for the study from across the metro Atlanta area, researchers were able to convene a more diverse group of patients than other previous studies, with roughly half of the participants self-identified as African-American or Hispanic.
“Our diverse sample demonstrated that the evidence-based psychotherapy and medication treatments recommended as first line treatments for depression can be extended with confidence beyond a white, non-Hispanic population,” says Dunlop.
“Ultimately our studies show that clinical characteristics, such as age, gender, etc., and even patients’ preferences regarding treatment, are not as good at identifying likely treatment outcomes as the brain measurement,” adds Mayberg.
[ARTICLE] Perceived ability to perform daily hand activities after stroke and associated factors: a cross-sectional study – Full Text
Despite that disability of the upper extremity is common after stroke, there is limited knowledge how it influences self-perceived ability to perform daily hand activities. The aim of this study was to describe which daily hand activities that persons with mild to moderate impairments of the upper extremity after stroke perceive difficult to perform and to evaluate how several potential factors are associated with the self-perceived performance.
Seventy-five persons (72 % male) with mild to moderate impairments of the upper extremity after stroke (4 to 116 months) participated. Self-perceived ability to perform daily hand activities was rated with the ABILHAND Questionnaire. The perceived ability to perform daily hand activities and the potentially associated factors (age, gender, social and vocational situation, affected hand, upper extremity pain, spasticity, grip strength, somatosensation of the hand, manual dexterity, perceived participation and life satisfaction) were evaluated by linear regression models.
The activities that were perceived difficult or impossible for a majority of the participants were bimanual tasks that required fine manual dexterity of the more affected hand. The factor that had the strongest association with perceived ability to perform daily hand activities was dexterity (p < 0.001), which together with perceived participation (p = 0.002) explained 48 % of the variance in the final multivariate model.
Persons with mild to moderate impairments of the upper extremity after stroke perceive that bimanual activities requiring fine manual dexterity are the most difficult to perform. Dexterity and perceived participation are factors specifically important to consider in the rehabilitation of the upper extremity after stroke in order to improve the ability to use the hands in daily life.
Disability of the upper extremity is common after stroke and almost 50 % of those affected have remaining impairments more than three months post-stroke [1, 2]. The impairments often lead to difficulties in performing daily hand activities , especially those that require the use of both hands, i.e., bimanual activities . The ability to perform bimanual activities is therefore an important goal in stroke rehabilitation, regardless of which hand that is affected .
The ability to perform daily activities can be objectively assessed by observations of different tasks in a standardized environment or by patient-reported questionnaires. The advantage of using questionnaires is that they often provide a better understanding of an individual’s self-reported everyday difficulties and thereby enable clinicians to design more individually targeted rehabilitation interventions . One questionnaire that is recommended for persons with disability of the upper extremity after stroke is the ABILHAND Questionnaire [4, 7, 8]. It assesses self-perceived ability to perform daily bimanual activities. Previous studies have focused on evaluating the psychometric properties of the ABILHAND [4, 8], but no study has thoroughly described which activities persons in a stable phase post stroke perceive difficult to perform.
In order to improve functioning of the upper extremity after stroke, it is important to understand which factors affect self-perceived ability to perform daily hand activities. Previous studies have shown that single factors, such as motor function, muscle strength, spasticity, somatosensation, dexterity, perceived participation and life satisfaction are moderately to strongly associated with the perceived ability [4, 9, 10, 11, 12, 13, 14, 15, 16, 17]. However, as several factors simultaneously may influence the ability to perform daily hand activities there is a need to understand how these factors are associated with the performance. To the best of our knowledge, only one study  has evaluated this association in persons in a stable phase after stroke. In that study by Harris and Eng , muscle strength, spasticity, somatosensation and pain were included in multivariate analyses and the authors found that muscle strength in the upper extremity and spasticity were the strongest contributing factors to the perceived ability to use the hands in daily activities. However, dexterity was omitted as a potentially associated factor in the analysis, which was addressed as a limitation of the study. In other studies, gender, dominance of the affected upper extremity, and social and vocational situations have been shown to be important factors for overall functioning after stroke [18, 19, 20, 21]. However, it is unclear how these factors are associated with the self-perceived ability.
Taken together, despite that disability of the upper extremity is common after stroke there is limited knowledge of which daily activities that are perceived difficult to perform and which factors that affect the self-perceived performance. The majority of previous studies have evaluated how single or few factors are associated with perceived daily hand activities. Thus, there is a need for more studies that take several factors into account simultaneously.
The aim of this study was to evaluate a) which daily activities persons with mild to moderate impairments of the upper extremity after stroke perceive difficult to perform and b) how several factors (age, gender, social and vocational situation, affected hand, upper extremity pain, spasticity, grip strength, somatosensation, manual dexterity, perceived participation and life satisfaction) are associated with the self-perceived performance.