Stroke is a leading cause of disability in the United States.1 The Veterans Health Administration (VHA) of the Department of Veterans Affairs (VA) estimates that 15 000 veterans are hospitalized for stroke each year (VA HSR&D, 1997).

Forty percent of stroke patients are left with moderate functional impairments and 15% to 30% with severe disability.2 Effective rehabilitation interventions initiated early after stroke can enhance the recovery process and minimize functional disability. Improved functional outcomes for patients also contribute to patient satisfaction and reduce potential costly long-term care expenditures.

There are only 45 rehabilitation bed units (RBUs) in the VA today. Many veterans who have a stroke and are admitted to a VA Medical Center will find themselves in a facility that does not offer comprehensive, integrated, multidisciplinary care. In a VA rehabilitation field survey published in December 2000, more than half of the respondents reported that the “rehabilitative care of stroke patients was incomplete, fragmented, and not well coordinated” at sites lacking a RBU (VA Stroke Medical Rehabilitation Questionnaire Results, 2000).

In Department of Defense (DoD) medical treatment facilities, approximately 20 000 active-duty personnel and dependents were seen in 2002 for stroke and stroke-related diagnoses according to ICD-9 coding.3 Comprehensive treatment for stroke patients in DoD medical facilities is given primarily at medical centers. Smaller DoD community hospitals may have limited resources to see both inpatients and outpatients, relying more on the TRICARE network for ongoing stroke rehabilitation services.

A growing body of evidence indicates that patients do better with a well-organized, multidisciplinary approach to post-acute rehabilitation after a stroke.4–6 The VA/DoD Stroke Rehabilitation Working Group only focused on the post–acute stroke rehabilitation care.

Duncan and colleagues7 found that greater adherence to post-acute stroke rehabilitation guidelines was associated with improved patient outcomes and concluded “compliance …

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Management of Adult Stroke Rehabilitation Care: a clinical practice guideline.

A comprehensive evidence-based review of stroke rehabilitation was created to be an up-to-date review of the current evidence in stroke rehabilitation and to provide specific conclusions based on evidence that could be used to help direct stroke care at the bedside and at home. A literature search using multiple data-bases was used to identify all trials from 1968 to 2001. Methodological quality of the individual randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) quality assessment scale. A five-stage level-of-evidence approach was used to determine the best practice in stroke rehabilitation. Over 403 treatment-based articles investigating of various areas of stroke rehabilitation were identified. This included 272 randomized controlled trials.

An Evidence-Based Review of Stroke Rehabilitation

Botulinum toxin, the most potent biological toxin, has become a powerful therapeutic tool for a growing number of clinical applications. This review draws attention to new findings about the mechanism of action of botulinum toxin and briefly reviews some of its most frequent uses, focusing on evidence based data. Double blind, placebo controlled studies, as well as open label clinical trials, provide evidence that, when appropriate targets and doses are selected, botulinum toxin temporarily ameliorates disorders associated with excessive muscle contraction or autonomic dysfunction. When injected not more often than every three months, the risk of blocking antibodies is slight. Long term experience with this agent suggests that it is an effective and safe treatment not only for approved indications but also for an increasing number of off-label indications.

https://jnnp.bmj.com/content/jnnp/75/7/951.full.pdf

Botulinum toxin in clinical practice.

A group of clinicians from across Europe experienced in the use of botulinum toxin type A for the treatment of spasticity following acquired brain injury gathered to develop a consensus statement on best practice in managing adults with spasticity. This consensus table summarizes the current published data, which was collated following extensive literature searches, their assessment for level of evidence and discussion among the whole group. Published information is supplemented by expert opinion based on clinical experience from 16 European countries, involving 28 clinicians, who treat an average of approximately 200 patients annually, representing many thousand spasticity treatments with botulinum toxin per year.

/pdf/european-consensus-table-on-the-use-of-botulinum-toxin-type-49dku2vut2.pdf

European Consensus Table On the Use of Botulinum Toxin Type a in Adult Spasticity

Menthol is a naturally occurring cyclic terpene alcohol of plant origin, which has been used since antiquity for medicinal purposes. Its use in dermatology is ubiquitous, where it is frequently part of topical antipruritic, antiseptic, analgesic, and cooling formulations. Despite its widespread use, it was only recently that the mechanism by which menthol elicits the same cool sensation as low temperature was elucidated upon, with the discovery of the TRPM8 receptor. Although almost 5 years have passed since the discovery of this receptor, many dermatologists are still unaware of menthol's underlying target. The purpose of this review is to highlight the recent advances in the mechanism of action of menthol and to provide an overview of its dermatologic applications.

Menthol: a refreshing look at this ancient compound

Locally acting treatments for spasticity such as nerve and motor point blocks have the advantage of reducing harmful spasticity in one area, while preserving useful spasticity in another area. This randomized, double-blind study is the first trial that was designed to find out whether botulinus toxin Type A and phenol relieves the signs and symptoms of ankle plantar flexor and foot invertor spasticity after stroke and if either of these methods offers any advantages and disadvantages over the other. Twenty patients who were included in this preliminary study were randomly assigned to receive a single treatment of 400 mouse units of botulinus toxin Type A injected into the calf muscles or to receive a tibial nerve blockade with 3 ml of 5% phenol. A combination of subjective and objective measures were used to assess functional change at baseline and at Weeks 2, 4, 8, and 12. At follow-up, significant improvement (P 0.05). When those variables were compared between the two groups, the change in the Ashworth score at Weeks 2 and 4 was significantly better in the group that received botulinus toxin Type A (P 0.05). The decrease in clonus duration that was detected by electromyography was significant in both groups at all visits, but the decrease in the group that received botulinus toxin Type A was significantly better at Weeks 2 and 4 (P < 0.05). It is concluded that both motor point injections with botulinus toxin Type A and tibial nerve blockade with phenol are effective in plantar flexor spasticity, but the changes were more significant in the group that received botulinus toxin Type A at Weeks 2 and 4, whereas there was not a significant difference between the two groups at Weeks 8 and 12. Future research should explore the long-term effect of these two treatment modalities.

Comparison of phenol block and botulinus toxin type A in the treatment of spastic foot after stroke: a randomized, double-blind trial.

This preliminary study was designed to investigate the effects of botulinus toxin Type A and phenol treatments on electrophysiologic tests evaluating spinal afferent and efferent motor pathways involved in spasticity. The questions posed were whether different types of mechanisms act on reducing spasticity with these different treatment modalities and whether the tests are correlated with clinical recovery. Twenty patients with lower limb spasticity secondary to stroke were randomly assigned to receive 400 mouse units of botulinus toxin Type A injected into the calf muscles or to receive a tibial nerve blockade with 3 ml of 5% phenol. The amplitudes of the Achilles tendon response, M response, H reflex response, and maximum H:M ratio and Achilles tendon response to H response ratio were recorded from the soleus muscle at baseline and at Weeks 2, 4, and 12. The most obvious change was a reduction in the amplitude of the tendon response in the group that received botulinus toxin Type A, and it was a reduction in the M response amplitude in the group that received phenol. The decrease in the tendon response amplitude and tendon response to H ratio in the group that received botulinus toxin Type A and the decrease in the M response amplitude in the phenol group were found to be well correlated with clinical recovery as assessed by the Ashworth scale. The findings suggested that botulinus toxin Type A injection decreases spasticity primarily by affecting the fusimotor system and muscle spindle, and the involvement of the alpha-motor fibers within the tibial nerve is the most likely factor contributing to the reduction of spasticity after phenol blockade. The therapeutic effectiveness of these agents could be assessed and followed up by the changes in electrophysiologic responses matching their mechanisms of action. The findings should be supported by further electrophysiologic techniques.

Mechanisms of action of phenol block and botulinus toxin Type A in relieving spasticity: electrophysiologic investigation and follow-up.

https://www.archives-pmr.org/article/S0003-9993(97)90331-2/pdf

Local heat effect on sympathetic skin responses after pain of electrical stimulus

Paralysis after use of a tourniquet during surgery is a well recognized complication. Based on the electrophysiologic findings, 35 cases referred to our electromyography laboratory have been diagnosed as tourniquet paralysis within a 3-yr period. This preliminary report suggests that tourniquet paralysis should be considered during clinical and electrophysiologic evaluations after primary nerve repairs.

Ramazan Aksit

Papers

Comparison of phenol block and botulinus toxin type A in the treatment of spastic foot after stroke: a randomized, double-blind trial.

Mechanisms of action of phenol block and botulinus toxin Type A in relieving spasticity: electrophysiologic investigation and follow-up.

Local heat effect on sympathetic skin responses after pain of electrical stimulus

Tourniquet paralysis after primary nerve repair.