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Anarchic hand syndrome (AHS) is a rare disorder characterized by unwilled, but seemingly purposeful movements of the affected upper limb which are perceived by the patients not to be under their control. It often interferes with goal-directed movements and bimanual tasks. At present there is no effective method of treatment of AHS. We report here a case of AHS following resection of a frontal lobe tumor and describe its effects on the patient's functional activities. The patient used avoidance behavior and mental concentration to overcome the disabling effect of AHS. These strategies appear to be useful in the management of AHS.

Developmental stammering is relatively common in the adult population. Stammering has a poor prognosis when it persists beyond adolescence and spontaneous or treatment-induced remission is very rare in adults. In this communication we report a case of life-long developmental stammering that resolved completely after the onset of a posterior circulation stroke and we speculate on the reason for this.

Water metabolism and the responses of the neurohypophysis to changes in plasma osmolality during the water loading and water deprivation tests were studied in nine patients with postviral fatigue syndrome (PVFS) and eight age and six-matched healthy control subjects. Secretion of arginine-vasopressin (AVP) was erratic in these patients as shown by lack of correlation between serum and urine osmolality and the corresponding plasma AVP levels. Patients with PVFS had significantly low baseline arginine-vasopressin levels when compared with healthy subjects. Patients with PVFS as a group also showed evidence of increased total body water content. These results may be indicative of hypothalamic dysfunction in patients with PVFS.

Objective: To study the efficacy, safety, and incidence of BtxA antibody formation with repeated treatments with BtxA in post-stroke upper limb muscle spasticity. Methods: The study was a prospective open label trial. Patients with established post-stroke upper limb spasticity received 1000 units of BtxA (Dysport) into five muscles of the affected arm on study entry. Treatment was repeated every 12, 16, or 20 weeks as clinically indicated. Each patient received a total of three treatment cycles. Efficacy of treatment was assessed using the Modified Ashworth Scale. Patients were assessed on study entry and on week 4 and 12 of each treatment cycle for all safety and efficacy parameters. Blood samples for BtxA antibody assay were taken at baseline and on completion of the trial. Results: Fifty one patients were recruited and 41 of them completed the study. Improvement from the cycle one baseline was observed in all the outcome measures. Mild to moderately severe treatment related adverse events were reported in 24% of cases. There were no serious adverse events. No BtxA antibodies were detected. Conclusion: BtxA at a dose of 1000 units Dysport was efficacious in the symptomatic treatment of post-stroke upper limb spasticity. The study suggests that this effect can be maintained with repeated injections for up to at least three treatment cycles, with duration of effect per cycle of between 12 and 20 weeks. BtxA was safe in the dose used in this study and did not induce the formation of detectable levels of neutralising BtxA antibodies.

At least two randomized controlled trials (RCTs) have shown botulinum toxin type A (BtxA) to be efficacious and safe when used in the management of muscle spasticity in children. However, the need to use standard treatment protocols in these studies obscures some aspects of routine clinical practice that may have important effect on clinical outcomes. The purpose of this study was to seek additional information on the use of BtxA that is not usually captured by RCTs. This was performed by reviewing the clinical practice of practitioners in 17 treatment centres in Europe. The details of treatment with BtxA, including the dose, site and frequency of injections and the use of anaesthesia or sedation, were abstracted from the patient's records. Information was also obtained on the response to treatment and the occurrence and severity of adverse events. The data on 758 children who received a total of 1,594 treatments in 17 different clinics in Europe were analysed. Ninety-four per cent of patients had cerebral palsy. There was a general agreement on the indications for treatment but the average dose of BtxA used varied between centres. One treatment centre used general anaesthesia (GA) prior to injections in most patients. The reported efficacy and adverse events profile was similar for all centres. The evidence from routine clinical practice for the efficacy and safety of BtxA in the management of muscle spasticity in children, as described in this study, is in agreement with that of most of the open-label and RCTs published to date. The present study also demonstrates the disagreement between clinicians on the optimal dose of BtxA for individual muscles and confirms that the injections can be carried out without GA in almost all cases.

Objective. To study the eAcacy and safety of botulinum toxin type A (BtxA) in the treatment of upper limb muscle spasticity, caused by stroke. Methods. This was a randomized, controlled trial. Patients received either placebo injections or a total of 1000 IU of BtxA (Dysport) into five muscles of the aAected arm. Muscle tone was assessed using the Modified Ashworth Scale (MAS). Other outcome measures were the change in the joint range of motion (ROM), the Barthel index, pain score, goal attainment and the subjective evaluation of benefit by patients and investigators. The patients were assessed blind to randomization at baseline and 4, 8, 12 and 16 weeks after treatment. Results. Fifty nine patients were recruited and received treatment. One patient was lost to follow-up before the last scheduled visit of the study. The group of patients who received BtxA had a significant reduction in the summed MAS score at week 4 compared with the placebo group (Pa 0.004). The magnitude of benefit over the 16 week follow-up period was significantly reduced for the BtxA group in the wrist (Pa 0.004) and the finger joints (Pa 0.001) when compared with the placebo. There was no statistically significant diAerence between the groups in the joint ROM, muscle pain, goal-attainment or the Barthel index scores at week 4 of the study. At week 16, the BtxA group showed significantly greater improvement in the passive ROM at the elbow (Pa 0.036). The patients’ global assessment of benefit at the end of the study showed that 16 (50%) patients in the placebo group had ‘much improved’ or had ‘some improvement’ compared with 24 (92.3%) patients in the BtxA group (Pa 0.007). The investigators’ rating for the same item was 16 (50%) and 23 (88.4%) patients, respectively (Pa 0.002). Sixteen and twenty patients in the BtxA and placebo groups, respectively, had an adverse event. The most frequently reported adverse events were accidental injury, respiratory and urinary tract infections and muscle pain. Conclusion. The findings of the present study suggest that treatment with BtxA in a dose of 1000 units reduces muscle tone in patients with post-stroke upper limb spasticity. This eAect is sustained for at least 16 weeks. BtxA is safe in the dose used in this study. Important note. The authors wish to emphasize that the botulinum toxin preparation used in this study was Dysport (Ipsen Ltd) which has a diAerent therapeutic equivalence from other commercially available product, Botox (Allergan Inc.).

Recent studies have shown a marked variation in the standards of healthcare for young people with disabilities in different regions of the UK and even within the same health district. Equity in the provision of healthcare is a fundamental principle of the NHS. However, this can only be measured against an agreed minimal standard of healthcare that serves as a benchmark for healthcare purchasers and providers. The aim of the present document is to develop a set of minimum standards of healthcare for children and adults with cerebral palsy (CP).The document was developed in two stages by a multi-professional and multi-disciplinary group of practitioners in the field of CP. Initially, members of the panel jointly formulated a statement of what they believed should be the minimal acceptable standards of healthcare in CP drawing on their own experience and the published scientific evidence. In the second stage the views of some of the relevant professional bodies and voluntary organizations on the draft statement were sought. The responses of these organizations were incorporated into the final document if agreed by the panel.Twenty-two recommendations were made. These were considered the minimum standards of care in a district general hospital. The emphasis was on the organisation and delivery of healthcare for children with CP. The statement is intended to stimulate debate especially in relation to the equity of service provision throughout the country and may be used to inform purchasers of healthcare. Similarly, it may also be useful to providers of healthcare as an audit tool.

The primary objective of this study was to examine the effects of the provision of environmental control systems (ECSs)on the user's functional independence and the amount of care he or she needed. A secondary objective was to establish whether accessibility, acceptability and reliability of ECSsand training in their use have increased the benefits derived from them. A questionnaire and semi-structured interview were used to obtain the responses of users of ECSsand their carers in the County of Dorset, England. Sixteen users of ECSs and 13 carers were recruited for the study. All users lived at home and were frequently left alone for periods of up to 13 hours per day. Functional gains were reported in all aspects of function that were studied, but statistically significant improvement was found in 7 out of the 17 functions evaluated. The maximum benefit appeared to be in the functions relating to home security needs. There was also evidence that the provision of ECSshad reduced the amount of care needed by disabled users. There was strong agreement between the responses of users and carers. No conclusion could be reached regarding the secondary objective of the study. The provision of ECSsappears to have increased the functional independence of disabled users and their sense of wellbeing and reduced the burden of their care.

Severe muscle spasticity is common in patients with neurological disease. It is often associated with pain and distressing spasms, and frequently leads to functional motor disability. Antispasticity drugs usually result in systemic adverse effects, and peripheral nerve blocks have some disadvantages such as sensory loss and painful dysaesthesiae. In recent years botulinum toxin type A (BT/A) has been advocated for the treatment of muscle spasticity. We studied, using a functional assessment scale, the effects of BT/A on the patients' symptoms and the functional disability due to spasticity in five children and eight adults who were referred for treatment. In 10 patients the treatment goals were achieved, and children generally had a better and more sustained response than adults. There were no adverse effects reported. The present study suggests that BT/A is safe and effective in improving the motor functional disability which is often associated with severe localized muscle spasticity.

Objective: To examine the attitudes of a rural community in southern India toward its disabled members. Design: Prospective cross-sectional study Method: One hundred and twenty randomly selected villagers around the town of Vellore in southern India were invited to take part in the study. The attitudes towards individuals with physical disabilities were examined using a modified version of the Scale of Attitudes Toward Disabled Persons (SADP). The questionnaire was administered in its original English format with simultaneous translation into Tamil. Results: Data were complete in 111 cases, 82% of whom showed a positive attitude toward people with disability. Gender and employment status did not appear to have an influence on whether the respondent regarded disabled people in a positive or negative way but most older individuals expressed prejudice and/or challenged the rights of disabled people to equal opportunities in education, employment and social integration. Further data analysis demonstrated that more subjects with than without a disabled family member supported the rights of disabled individuals to education, employment and social integration. By contrast, the items of SADP which described the personal attributes of disabled people did not discriminate between the two groups. Conclusion: The attitudes of the rural community studied toward people with disabilities were unrelated to the sex or educational status of the respondents but was influenced by their age. This suggests that older subjects in rural communities in developing countries should be the main target for educational programmes which promote positive images of disability.

An interdisciplinary outpatient rehabilitation clinic was set up to assess patients with severe and complex disabilities. The rehabilitation team consisted of a physician, a nurse, a community liaison occupational therapist, a community physiotherapist and a speech and language therapist. Each patient was assessed in the clinic for half a day. The patients' carers were encouraged to attend. A total of 25 consecutive new patients were studied. The findings of the study suggest that the range of therapeutic interventions carried out during the outpatient clinic visit were comparable to the standard model of care. To evaluate the effectiveness of this service in preventing hospital admissions the case histories of the study patients were presented to three consultants in rehabilitation medicine who were asked to give their management decision on each case, but were not told the objectives of the study. Analysis of the consultants' decisions showed that there was agreement between all consultants that five patients needed admission to hospital for evaluation or treatment and two out of the three physicians said that they would have admitted a further eight patients. In fact, none of our patients was admitted, which suggests that the model of outpatient multi disciplinary assessment service proposed here may reduce the need for admissions to hospital.

The use of phenol and alcohol nerve blocks in the treatment of localized muscle spasticity is well established. However, a number of questions relating to this procedure are still unanswered. This article presents experience of the effectiveness of chemical neurolysis in the treatment of severe lower limb muscle spasticity in 28 patients who had a total of 56 nerve blocks performed during a follow-up period of between four and 18 months.

The Barthel Index (BI) in its original format must be completed by a therapist. To overcome this disadvantage a self-administered version of the BI was designed, the modified Barthel Index (MBI). In the present study the MBI was validated against the original BI and also the Stanford Health Assessment Questionnaire (HAQ) in 33 patients with rheumatoid arthritis (RA). There was a close correlation between BI and MBI in eight out of the 10 items of the scale and in the overall score. Similarly, there was a good correlation between MBI and HAQ but only in patients with mild disability. Further analysis of data showed that the HAQ overestimated the degree of disability in patients with RA and may be less reliable than the MBI in measuring functional independence in these patients.

A significant proportion of hospital beds is usually occupied by patients awaiting placement, home adaptations or other care provisions by Social Services. Anecdotal evidence suggests that the number of 'acute bed-blockers' has fallen since the implementation of the Community Care Act (CCA). The aim of the present study was to examine the validity of this claim. Records of patients discharged from Southampton Rehabilitation Unit in the twelve months before and after the implementation of the CCA ( n = 72) were analysed. Contrary to previous reports, there was no difference in the overall length of hospital stay or the time patients spent awaiting discharge after they had achieved functional independence. The reasons for the inappropriate hospitalization were also similar in the two groups and were mainly due to shortage of residential care places for patients with disabilities and delays in the provision of equipment, services and home adaptations.

Different criteria are used to define the terms mid-stance (MST) and mid-swing (MSW) when describing the gait cycle. None of these definitions is universally accepted. This causes difficulties with the interpretation of gait analysis data and hinders the comparison between the different studies. The aim of the present study was to compare three definitions of MST and MSW by examining the gait of a group of healthy children.A prospective comparison of three commonly used definitions of the MST and MSW events of the gait cycle.The timing of the temporal, kinematic and kinetic MST and MSW of the gait cycle.Thirty healthy 8 - 10-year-old children were studied. There was no consistent correlation between the timing of the chosen definitions of MST and MSW. However, there was a tendency for the timing of the temporal and kinetic MST and MSW to occur, respectively, at approximately 30 and 80% of the gait cycle.The temporal definition of MST and MSW as the midpoints in time of the respective phases of the gait cycle appears to be more appropriate than other definitions. The use of this definition may prevent misunderstanding and permit comparison of the results of the different gait analysis studies.

Coincidental acute illness is common in patients with chronic progressive or stable neurological disability. Although the presentation of acute illness in these patients is often similar to that in people without pre-existing disability, sometimes it may be atypical. In addition, an adequate medical history is often difficult to obtain in patients with advanced neurological disease, for example because of the presence of aphasia, severe dysarthria, or cognitive impairment. In these circumstances early and accurate diagnosis of acute medical and surgical emergencies requires both clinical acumen and a high index of suspicion. The aim of this article is to describe the main atypical manifestations of acute illness in patients with chronic disabling neurological disorders.

Background and Purpose The aim of the present study was to examine the value of pulse oximetry in the diagnosis of aspiration by comparing it with the gold standard, videofluoroscopy, by use of a prospective, controlled, single-blind study design. Methods Pulse oximetry was performed simultaneously with videofluoroscopy in 54 consecutive dysphagic stroke patients. Oxygen saturation measurements were taken before the videofluoroscopic examination (baseline), on swallowing and continuously for 2 minutes after swallowing, and 10 minutes later. Results Pulse oximetry reliably predicted aspiration or lack of it in 81.5% of cases. The predictive value of the test was low in patients aged ≥65 years and possibly those with chronic lung disease. One smoker also had a false-negative pulse oximetry result, ie, normal oxygen saturation despite radiological evidence of aspiration. Conclusions Pulse oximetry is a reliable method of diagnosis of aspiration in most dysphagic patients. However, careful interpretation of pulse oximetry data is necessary in older subjects, possibly those with chronic pulmonary disease, and smokers. The method is noninvasive, simple, and quick, and can be used routinely in the clinical assessment of dysphagic patients.

Objective. To examine the correlation between an impairment-level and a functional-level assessment scale of aphasia.Design. Prospective, longitudinal study.Setting. A stroke rehabilitation unit.Subjects. Sixty-seven aphasic acute stroke patients who were undergoing a multi-disciplinary rehabilitation programme, including conventional speech and language therapy (SLT).Intervention. Patients were assessed on study entry and 4, 8, 12 and 24 weeks after the start of SLT. The language impairment was assessed with the Western Aphasia Battery (WAB) and the communicative functional limitation associated with aphasia was measured with the Communicative Effectiveness Index (CETI).Results. There was a statistically significant correlation between the two scales for all assessment periods (Pearson's r = 0.71; P

Impairment of language function (aphasia) is one of the most common neurological symptoms after stroke. Approximately one in every three patients who have an acute stroke will suffer from aphasia. The estimated incidence and prevalence of stroke in Western Europe is 140 and 800 per 100,000 of the population. Aphasia often results in significant disability and handicap. It is a major obstacle for patients to live independently in the community. When recovery from aphasia occurs, it is usually incomplete and patients are rarely able to return to full employment and other social activities. Currently, the main treatment for aphasia is conventional speech and language therapy. However, the effectiveness of this intervention has not been conclusively demonstrated and empirical observations suggest that spontaneous biological recovery may explain most of the improvement in language function that occurs in aphasics. The generally poor prognosis of the severe forms of poststroke language impairment (Broca, Wernicke and global aphasia), coupled with the limited effectiveness of conventional speech and language therapy has stimulated the search for other treatments that may be used in conjunction with speech and language therapy, including the use of various drugs. Dopamine agonists, piracetam (Nootropil), amphetamines, and more recently donepezil (Aricept), have been used in the treatment of aphasia in both the acute and chronic phase. The justification for the use of drugs in the treatment of aphasia is based on two types of evidence. Some drugs, such as dextroamphetamine (Dexedrine), improve attention span and enhance learning and memory. Learning is an essential mechanism for the acquisition of new motor and cognitive skills, and hence, for recovery from aphasia. Second, laboratory and clinical data suggest that drug treatment may partially restore the metabolic function in the ischemic zone that surrounds the brain lesion and also has a neuroprotective effect following acute brain damage. An example of this is the nootropic agent piracetam. Extensive animal studies have demonstrated the beneficial effects of this and other drugs on neural plasticity, but data on humans are still sparse. This review provides a critical analysis of the current evidence of the effectiveness of these drugs in the treatment of acute and chronic aphasia.

The perception of a phantom limb is commonly reported after amputations. However, only a few cases have been described after a stroke. This article presents a patient who reported a supernumerary phantom limb (pseudopolymelia) after spontaneous intracerebral haemorrhage and discusses the possible underlying mechanisms for this rare phenomenon.

The correct research design is crucial in establishing whether treatments for complex neurological disorders are effective The effectiveness of botulinum toxin type A (BtxA) in reducing post-stroke muscle hypertonia and its complications has been demonstrated in adult patients in at least eight large randomised controlled trials (RCTs).1–8 The clinical benefits were reported when diverse treatment protocols and different dose schedules and injection techniques were used for the management of the same clinical indication. Nonetheless, some doubt as to the value of this treatment remain.9 What is the explanation for this apparent paradox? The contradiction may be explained by the inadequate design of these studies and the inherent difficulties with the interpretation of the results of RCTs of a drug treatment that is carried out in the context of rehabilitation for a person with chronic neurological disability. The WHO classification of functioning, disability, and health10 provides a useful framework for understanding the complex relation between the statistical significance and the clinical significance of a given treatment and helps to explain the complexity of rehabilitation research. A statistically significant change at the level of impairment (as a result of the intervention) may not alter the subject’s functional abilities or potential for social participation. The outcome of treatment with BtxA is clinically significant only if it results in the full or partial attainment of functional goals that are meaningful to the recipient of this treatment. An example of such outcomes is the achievement of safe walking and prevention of falls in a patient with dynamic foot equinus after BtxA injections into the calf muscles. Successful treatment reduces muscle …

Disability was measured in 33 patients with rheumatoid arthritis (RA) using the Stanford Health Assessment Questionnaire (HAQ) and a self-administered version of the Barthel index (BI). There was no significant disagreement between the two methods, although the HAQ showed a tendency to overestimate the degree of disability slightly. The findings suggest that the B1 is as reliable as the HAQ in the assessment of functional independence with activities of daily living in patients with RA. it also has the advantage of evaluating bladder and bowel control which is often affected in these patients. Most therapists are more familiar with the B1 than with the HAQ. The B1 could, therefore, be recommended for measuring rehabilitation gains in patients with RA.

The involuntary movements of the paretic arm during ambulation and other motor activities are known as associated upper limb reactions (ARs). ARs occur in 80% of stroke patients with spastic hemiplegia and often interfere with balance and safe mobilization. It is hypothesized that the treatment of localized muscle spasticity with botulinum toxin type A (BtxA) would abolish the ARs and improve balance and mobility.This hypothesis will need to be tested in a randomized controlled trial (RCT). The aim of the present pilot study is to obtain preliminary data to inform the design of a future RCT. Eight patients received a single injection of 500 units of BtxA (Dysport((R)) Ipsen, Ltd) into the biceps brachii of the paretic arm. The patients' balance and mobility were assessed before and 2, 4 and 6 weeks after treatment using observational gait analysis and other subjective assessment scales.There was a significant reduction of the ARs after treatment but this did not appear to improve the patients' balance or mobility as assessed by the clinicians. Interestingly, seven out of the eight patients reported improvement in their walking.The discrepancy between the observed and reported effects of treatment could be due to the poor sensitivity of the outcome measures used in this study.

Dysphagia is common in patients with neurological disorders. It may result from lesions in the central or peripheral nervous system as well as from diseases of muscle and disorders of the neuromuscular junction. Drugs that are commonly used in the management of neurological conditions may also precipitate or aggravate swallowing difficulties in some patients. Neurogenic dysphagia often results in serious complications, including pulmonary aspiration, dehydration, and malnutrition. These complications are usually preventable if the dysphagia is recognised early and managed appropriately. The act of swallowing may be viewed as three discrete but inter-related physiological stages: the oral, pharyngeal, and oesophageal phases. The oral phase is initiated voluntarily and serves to prepare the food bolus and deliver it to the pharynx. An adequately prepared and sufficiently large and cohesive food bolus triggers the swallow reflex by stimulating the sensory receptive field in the soft palate, dorsum of the tongue, epiglottis, and posterior pharyngeal wall. Simultaneously the larynx closes and the velum retracts upwards to prevent the entry of food and fluid into the nasal cavity. Coordination of respiration and swallowing is necessary to prevent the penetration of food into the airways. This is achieved by transient cessation of breathing, a process known as deglutition apnoea. The pharyngeal phase is followed by a prolonged expiration to avert mist aspiration, that is inhalation of air held in the pharynx (which is usually saturated with fluid and food particles). The swallow reflex triggers the oesophageal peristaltic movements and causes relaxation of the circopharyngeal sphincter. This, combined with the effects of gravity, facilitates the transmission of food down into the stomach. Several factors contribute to the swallowing difficulties encountered in patients with neurogenic dysphagia. These include weakness of the oral musculature and tongue movements, failure to form a cohesive food bolus, reduced sensitivity of the …

Background and Purpose —We sought to define an effective and safe dose of botulinum toxin type A (Dysport) for the treatment of upper limb muscle spasticity due to stroke. Methods —This was a prospective, randomized, double-blind, placebo-controlled, dose-ranging study. Patients received either a placebo or 1 of 3 doses of Dysport (500, 1000, 1500 U) into 5 muscles of the affected arm. Efficacy was assessed periodically by the Modified Ashworth Scale and a battery of functional outcome measures. Results —Eighty-three patients were recruited, and 82 completed the study. The 4 study groups were comparable at baseline with respect to their demographic characteristics and severity of spasticity. All doses of Dysport studied showed a significant reduction from baseline of muscle tone compared with placebo. However, the effect on functional disability was not statistically significant and was best at a dose of 1000 U. There were no statistically significant differences between the groups in the incidence of adverse events. Conclusions —The present study suggests that treatment with Dysport reduces muscle tone in patients with poststroke upper limb spasticity. Treatment was effective at doses of Dysport of 500, 1000, and 1500 U. The optimal dose for treatment of patients with residual voluntary movements in the upper limb appears to be 1000 U. Dysport is safe in the doses used in this study.

Objective: Safe swallowing may be achieved in most patients with neurogenic dysphagia by manipulating the viscosity of ingested fluids. However, in clinical practice fluids are thickened using subjective judgement. This may lead to errors in the preparation of drinks to the prescribed viscosity. The aim of the present study is to examine whether the use of a viscometer improves the dietary management of dysphagic stroke patients. Study design: A randomized controlled study design was used. The speech and language therapist determined the optimal fluid thickness for each patient. The prescribed fluid viscosity for the study group was obtained using a viscometer. Patients in the control group received fluids prepared according to current practice, i.e. the amount of thickener required to produce the prescribed viscosity was judged subjectively by the nursing staff. The two methods of fluid thickening were used for seven consecutive days. Assessment was made blind to randomization. Main outcome measure: Pulmonary aspiration, assessed clinically and with pulse oximetry. If the patient did not drink all the fluid that was offered the residue was measured. Results: Ten patients in the study group ( n = 23) and nine in the control group ( n = 23) aspirated. The mean viscosity of fluids offered to patients in the control group was significantly higher than that of the study patients. There was a statistically significant correlation between the viscosity and the residual volume of fluid (Pearson's test: r = 0.7, p Conclusion: Manipulation of fluid thickness using objective measurements with a viscometer may improve the dietary management of dysphagic stroke patients.

A 31-year-old right-handed man was admitted to hospital with vomiting, severe headaches, photophobia and weakness of the left arm and leg. There was no medical or family history of note. He smoked about 20 cigarettes a day. On examination, he was drowsy but rousable to a Glasgow Coma Scale of 15/15. There was mild neck stiffness but Kernig's sign was negative. His oral body temperature on admission was 35.7°C. The radial pulse was 70 beats/min, regular and of good volume. Blood pressure was 125/60 mmHg. Examination of the nervous system confirmed severe flaccid left hemiparesis (muscle power MRC 3/5 and 0/5 in the lower and upper limbs, respectively). There was also a left upper motor neurone facial weakness. Tendon reflexes were brisk on the left side and the left plantar response was extensor. There were no sensory signs, visual field defects or dyspraxia. Language function appeared intact. Formal psychological assessment …

A detailed pathological description of the muscle findings in a case of the neuroleptic malignant syndrome (NMS) following ingestion of lysergic acid diethylamide (LSD) is given, including the first ultrastructural analysis. Focal necrosis, oedema, and hypercontraction of fibres with glycogen and lipid depletion, were identified, all of which had resolved completely a year later. The findings are compared with those in malignant hyperthermia. It is suggested that the results support the view that in NMS, the muscle rigidity is due to central mechanisms and, in both this disorder and malignant hyperthermia, it is responsible for the hyperpyrexia and its life-threatening complications.

A case of localised Wegener's granulomatosis presenting with central nervous system symptoms and signs is described. The difficulties of early diagnosis are high-lighted and the diagnostic criteria of the disease are discussed.

Objective: To examine the factors which influence the length of hospitalization of stroke patients. Design: Analysis of the relative importance of 10 preselected variables on the length of hospital stay of all patients admitted with a clinical diagnosis of stroke. The data were collected prospectively. Setting: Two teaching hospitals serving the city of Southampton and southwest Hampshire, England (approximate population 450 000). Subjects: Forty-six consecutive stroke patients. Results: Data were complete on 38 patients. The mean and (median) length of hospital stay was 74.9 (80.5) days for men and 74.7 (73.5) for women. The mean age of women in the study sample was higher than that of men (73.2 vs 71.6). Patients who were less than 70 years of age stayed shorter periods in hospital than older subjects. Other factors associated with shorter hospitalization were a stroke type other than total anterior circulation infarct, a Barthel score of 12 or more on admission or at the time of discharge and a frequency of consultants' ward rounds of more than one per week. A delay in the provision of equipment and home adaptations and waiting for placement in a private nursing home were the best predictors of long hospital stays of stroke patients. Conclusions: Early liaison of rehabilitation staff with Social Services in order to secure the quick provision of environmental aids and adaptations or placement in residential care of stroke patients with a poor prognosis for functional recovery would probably reduce the unnecessary hospitalization of these patients.

Previous studies of speech dysfunction in patients with Parkinson's disease (PD) consisted of postal surveys, which rely on the subjective opinions of patients, or were primarily focused on the detailed assessment of impairments without addressing the disabilities resulting from them. Similarly, the impact of the communication disability on the patient's everyday life was not assessed. The aim of the present study was to examine the prevalence of verbal communication disability in these patients, using a validated objective measurement tool. A secondary aim was to establish the patients' awareness of their disability and its impact on their lifestyle. Verbal communication disability was examined in 48 patients with PD using a modified version of the Intelligibility of Dysarthric Speech Assessment Scale. Nearly two-thirds of patients had reduced intelligibility of speech but this was mild, causing no disability, in the majority of them. Two out of seven patients with severely or moderately severely reduced intelligibility of speech were unaware of their disability, and none of the patients reported that the speech difficulties interfered with their lifestyle. The study also identified some predictors of verbal communication disability in these patients.

OBJECTIVE--To study the dynamic function of hypothalamic 5-hydroxytryptamine receptors in patients with postviral fatigue syndrome. DESIGN--Prospective comparison of patients with postviral fatigue syndrome with two control groups. SETTING--Department of neurology, University of Glasgow, Southern General Hospital; department of psychiatry, St James9s Hospital, Dublin. SUBJECTS--15 patients with postviral fatigue syndrome, 13 age and sex matched healthy subjects, and 13 patients with primary depression. MAIN OUTCOME MEASURES--Serum prolactin concentrations before and one, two, and three hours after administration of buspirone. RESULTS--Because of the effects of sex hormones on prolactin secretion data for men and women were analysed separately. There was no significant difference in baseline prolactin concentrations between patients with postviral fatigue syndrome and healthy subjects or those with primary depression. However, the percentage difference between peak and baseline values was significantly higher in patients with postviral fatigue syndrome than the control groups (one way analysis of variance: women, p = 0.003; men, p = 0.004). CONCLUSIONS--The results suggest upregulation of hypothalamic 5-hydroxytryptamine receptors in patients with postviral fatigue syndrome but not in those with primary depression. The buspirone challenge test may therefore be useful in distinguishing these two conditions. Larger studies are required to explore the potential value of drugs acting on central 5-hydroxytryptamine receptors in the treatment of patients with the postviral fatigue syndrome.

Phantom phenomena are common complications of limb amputations and may occasionally follow traumatic paraplegia and severe injuries of peripheral nerves. However, they have not been previously reported in patients with non-traumatic paraplegia. The following case history describes a patient with transverse myelitis resulting in complete paraplegia who experienced persistent movements and abnormal positions of her paralysed lower limbs. These findings suggest that disruption of the anatomical and functional integrity of the spinal cord may be the most important factor in the pathogenesis of phantom sensations. A 61 year old woman presented with severe weakness of both legs, skin sensory loss and paraesthesia of the lower limbs, and bowel and bladder symptoms. She was well until 3 months earlier when she started to develop a tingling sensation and numbness over the outer side of her left leg. These symptoms gradually progressed and by the time she was admitted to hospital she had paraesthesia and sensory impairment of the whole of the left leg and in the distal half of the right leg. A month before admission she had become unsteady on her feet and developed urinary frequency, urgency of micturition, and constipation. There was also a rapidly progressive weakness of both legs, but no other symptoms. Four years earlier the patient had had paraesthesia in both feet. This was thought to be due to peripheral neuropathy, but the diagnosis was not confirmed with neurophysiological tests. The symptoms resolved in a few weeks. The patient had …

Many different neurological and psychiatric syndromes follow viral infections, but their clinical pictures and pathogeneses are poorly understood. The syndromes include acute disseminated encephalomyelitis (post-infectious encephalomyelitis), the Guillain-Barre syndrome (post-infectious neuritis) and Reye's syndrome. Recently, attention has been focused on another common postviral neurological syndrome, i.e. the postviral fatigue syndrome (PVFS)--termed myalgic encephalomyelitis (ME) and a host of other designations. PVFS occurs both sporadically and in epidemics, with cases being reported from all over Europe, the United States, Australasia and South Africa. It is difficult to make the diagnosis and this has meant, in the past, that it is not until an epidemic has occurred that random cases which presented in the preceding years are realised to represent the same condition. With renewed interest in the syndrome and greater attention from physicians, however, diagnosis of sporadic cases is now becoming more common.

Three new cases of limbic encephalitis in association with malignancy are reported. The literature on this condition is reviewed and the clinical, laboratory and histopathological features of cases proven at necropsy are correlated. The possible pathogenic mechanism of this disorder is discussed.

Early diagnosis of Parkinson’s disease is often difficult. The insidious onset of the disease, its slow progression and the lack of laboratory tests to confirm the diagnosis contribute to this difficulty. Nevertheless, early diagnosis can be greatly facilitated by the systematic application of diagnostic clinical criteria and the selective use of radiological and laboratory tests.

Feinberg et al have recently reported the association between anosognosia for hemiplegia and the illusion of movement of the paralysed upper limb.1 They considered the illusion a form of confabulation that is distinct from other phantom phenomena. This explanation is not supported by my findings in a patient with a stroke who experienced transient purposeful movements of his paretic hand. The patient was a 66 year old right handed man who presented with acute onset weakness of his right arm and leg and slurring of his speech. He was known to be hypertensive and a non-insulin dependent diabetic patient. Neurological examination confirmed the presence of right hemiplegia with facial involvement and mild to moderately severe dysphasia. Muscle power, as measured by the Medical Research Council (MRC) scale, was 1/5 and 2/5 in the upper and lower limbs respectively. Spinothalamic and posterior column sensations were intact. No visual field defects were found on examination using the confrontation method. There was no astereognosis or sensory extinction of tactile or visual stimuli. The patient was alert and cooperative. His comprehension of spoken and written language was good … Dr Todd E Feinberg Dr Todd E Feinberg

Summary A case of necrosis of a pituitary tumour occurring in the context of diving is described. The presenting features and subsequent course suggested a brain stem vascular event. The tumour was not detected by routine computerized tomographic scanning, but was identified with magnetic resonance imaging. The possible pathophysiological mechanism is discussed.

A 69 year old female presented with eight discrete episodes of paraparesis over a period of six weeks. Each episode lasted between 10 and 30 minutes and resolved spontaneously. The cause of her symptoms was not established during life and at necropsy she was found to have granulomatous meningitis of the cerebral convexites. The clinical and pathological aspects of this rare condition are discussed.