Spasticity is a disorder of excess muscle tone associated with CNS disease. We hypothesized that botulinum toxin, a neuromuscular blocking agent, would reduce tone in spastic muscles after stroke. This randomized, double-blind, placebo-controlled, multicenter clinical trial evaluated the safety and efficacy of botulinum toxin type A (BTXA) in the treatment of chronic upper limb spasticity after stroke. Thirty-nine patients received IM injections of a total dose of either 75, 150, or 300 units of BTXA or placebo into the biceps, flexor carpi radialis, and flexor carpi ulnaris muscles. At baseline, patients demonstrated a mean wrist flexor tone of 2.9 and elbow flexor tone of 2.6 on the Ashworth Scale (0 to 4). Treatment with the 300-unit BTXA dose resulted in a statistically and clinically significant mean decrease in wrist flexor tone of 1.2 (p = 0.028), 1.1 (p = 0.044), and 1.2 (p = 0.026) points and elbow flexor tone of 1.2 (p = 0.024), 1.2 (p = 0.028), and 1.1 (p = 0.199) at weeks 2, 4, and 6 postinjection. In the placebo group, tone reduction at the wrist was 0.3, 0.2, and 0.0 and at the elbow was 0.3, 0.3, and 0.6 at weeks 2, 4, and 6 postinjection. BTXA groups reported significant improvement on the physician and patient Global Assessment of Response to Treatment at weeks 4 and 6 postinjection. There were no serious adverse effects. In this 3-month study, BTXA safely reduced upper extremity muscle tone in patients with chronic spasticity after stroke.

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Those patients who had botulinum toxin had significantly less pain toward the end of the first week after surgery. Reduction in spasm within the internal sphincter is the presumed mechanism of action. This is the first reported randomized, controlled trial using botulinum toxin in hemorrhoidectomy.

Recognition of non-verbal environmental sounds was investigated in 52 subjects with unilateral cerebro-vascular accidents and 18 age-matched normal controls. Impaired performance was most consistently found following cortical damage of homologous areas in either the left or the right hemisphere. Lesions involved the superior temporal gyrus (including the planum temporale), the inferior parietal lobe and the parietal operculum; this area appears to constitute the human auditory cortical processing area. We found different error patterns dependent upon the side of the lesion: patients with right hemisphere damage failed to discriminate between acoustically related sounds, patients with left hemisphere lesions tended to confuse semantically related sound sources. The impairment following right hemisphere damage was specific for non-verbal environmental sounds while left hemisphere damage was associated with disturbed semantic capabilities in multiple modalities.

T o work toward the goal of building healthier lives, free of cardiovascular diseases and stroke, the American Heart Association (AHA) and American Stroke Association (ASA) have developed a multifaceted strategy for improving the quality of care for stroke. A key feature of this strategy is the development of professional guidelines for evidence-based stroke care. Recommendations are provided for acute management, primary and secondary prevention, rehabilitation, stroke systems of care, and other domains of stroke care. 1-4The strength of the evidence supporting these recommendations is given, according to a specified grading system. For many aspects of care, there is widespread consensus that the intervention is beneficial, usually supported by strong scientific evidence including randomized controlled trials.Professional guidelines improve the delivery of evidencebased care; however, despite these guidelines, gaps between best evidence-based practice and actual practice persist.5 To close these gaps in quality of care, several organizations have developed systems to allow practitioners and healthcare organizations such as hospitals to quantify the quality of their care through performance measures. A performance measure is defined by the Agency for Healthcare Research and Quality as a "mechanism for assessing the degree to which a provider competently and safely delivers the appropriate clinical services to the patient within the optimal time period." 6 The AHA and American College of Cardiology Foundation have additionally suggested that performance measures should be based on the highest level of supportive evidence and have the greatest impact on health outcomes.7 Performance measures, in addition to supporting quality improvement activities, are specifically suitable for public reporting, external comparisons, and possibly pay-for-performance programs.As steward of the professional guidelines for stroke care, with a large group of volunteer expert clinicians with expertise in guideline creation and performance measurement, the AHA/ASA is uniquely positioned to develop high-quality performance measures based on the guidelines. Accordingly, in 2011 the AHA/ASA formed the Stroke Performance Oversight Committee to oversee development of stroke performance measures and quality metrics. Writing committees were commissioned for different domains of stroke care based on the care setting and type of cerebrovascular disease (eg, ischemic stroke versus intracerebral hemorrhage), roughly corresponding to the topics of the highest-impact professional guideline statements.8 This document provides the results of the writing committee on acute inpatient management of ischemic stroke.The primary intended purpose of these performance measures is to facilitate improved adherence to guideline-recommended care. The writing committee hopes that healthcare providers, healthcare organizations, and payers, such as the Centers for Medicare and Medicaid Services (CMS), may find these measures useful to measure and improve their qual...

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This pilot study obtained preliminary data on the effects of acupuncture treatment combined with a standard inpatient stroke rehabilitation program on poststroke motor recovery and physical function. Thirty-two patients with acute stroke were recruited and randomized to 1 of 2 treatment arms: standard rehabilitation (control group) or a combination of acupuncture and standard rehabilitation (acupuncture group). Baseline and discharge assessments were obtained on motor recovery as measured by the Fugl-Meyer (FM) Assessment and on physical function as measured by the Functional Independence Measure (FIM). Comparisons were made between the acupuncture and control group in total FM and FIM as well as for each subscale of the FM and FIM. No differences between treatment groups were found in the total FM or the total FIM. However, statistically significant benefit due to acupuncture was observed for the FM lower extremity motor function subscale (P = 0.01) and the tub/shower transfer mobility subscale of the FIM (P = 0.03). Marginally significant benefit due to acupuncture was noted for the toilet transfer mobility subscale of the FIM (P = 0.09). The effectiveness of acupuncture as an adjunct to standard poststroke rehabilitation programs may be demonstrated when more specific measures of stroke motor recovery and physical function are used.