Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

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The findings suggest that the early counseling intervention strategy trialed herein may not be effective for children and youth who experience significant postconcussion symptoms. Further research is needed to determine whether more intensive and integrated care would better serve children.

Deep brain stimulation (DBS) has been used to treat secondary dystonias caused by inborn errors of metabolism with varying degrees of effectiveness. Here we report for the first time the application of DBS as treatment for secondary dystonia in a 22-year-old male with X-linked adrenoleukodystrophy (X-ALD). The disease manifested at age 6 with ADHD, tics, and dystonic gait, and deteriorated to loss of ambulation by age 11, and speech difficulties, seizures, and characteristic adrenal insufficiency by age 16. DBS in the globus pallidus internus was commenced at age 18. However, after 25 months, no improvement in dystonia was observed (Burke-Fahn-Marsden (BFM) scores of 65.5 and 62 and disability scores of 28 and 26, pre-and post-DBS, respectively) and the DBS device was removed. Treatment with dantrolene reduced skeletal muscle tone and improved movement (Global Dystonia Rating Scores from 5 to 1 and BFM score 42). Therefore, we conclude that DBS was a safe but ineffective intervention in our case with longstanding dystonia, whereas treatment of spasticity with dantrolene did improve the movement disorder in this young man with X-ALD. ReportDeep brain stimulation (DBS) has demonstrated variable effectiveness in secondary dystonias caused by inborn errors of metabolism (e.g., homocystinuria, PKAN, GM1-gangliosidosis) (Andrews et al. 2010;Aydin et al. 2011). The present report of DBS in a now 22-year-old man with a diagnosis of X-linked adrenoleukodystrophy (X-ALD, OMIM# 300100) (Vidailhet et al. 2005) is its first reported application in X-ALD.The patient presented at age 6 with ADHD, tics, and a dystonic gait. Neuroimaging revealed symmetrical occipito-parietal demyelination and abnormal signal intensities in the basal ganglia and thalamus (Fig. 1). Diagnosis was confirmed by elevated very long chain fatty acids in plasma. He lost the ability to ambulate within 5 years, and was wheelchair-bound by age 11. His speech deteriorated and was barely intelligible by age 16. Seizure disorder and adrenal insufficiency were effectively controlled with carbamazepine and clobazam, and hydrocortisone, respectively. Initially the dystonia affected only the lower extremities, but quickly generalized. At age 11 years, mild athetoid movements of the head, neck, and extremities were observed. He held the neck in a flexed position, but was able to extend it on request. He had a tendency to elevate the right upper extremity, with his right wrist in a flexed position and fingers extended. There was mild intermittent flexion of the wrist. Knees were held in an extended position, with ankles plantar flexed and feet inverted (left greater than right). Tone was difficult to assess due to the dystonia. Deep tendon reflexes were brisk, especially at the knees; plantar responses were difficult to assess due to dystonia. Hoffman's sign was absent.For dystonia, botox, levodopa/carbidopamine, trihexyphenidyl, pergolide, and pramipexole were ineffective. Intrathecal baclofen to reduce muscle tone was refused by the patient.Repeat gadoli...

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ObjectiveTo describe the feasibility and safety of a randomised controlled trial (RCT) comparing active rehabilitation (AR) to treatment as usual (TAU) in adolescents with persistent symptoms following a sport-related concussion.DesignPartially blinded, pilot RCT.SettingOutpatient Rehabilitation Hospital.Participants13 adolescents enrolled and completed the study (10 girls, 3 boys). All were between the ages of 12–18 and were symptomatic for greater than 4 weeks. Participants were excluded if they had more than 1 concussion in the last year, any active mental health disorder, or if their concussion occurred more than 1 year from enrolment.InterventionParticipants were randomly allocated to TAU (occupational therapy and school recommendations) or AR. AR included aerobic exercise, positive visualisation techniques, and sport-specific exercises. AR sessions were supervised by a physiotherapist, and a blinded assessor monitored all participants weekly.Outcome measuresInvestigators monitored symptoms using the Post-Concussion Symptom Inventory. Secondary outcome measures included activity level, balance, mood, fatigue, and return to school.Main results125 individuals were screened over a 1.25 year period. Of the 22% of individuals deemed eligible, 15 declined to participate. Most commonly, individuals were excluded due to being unreachable, uninterested, or having more than one concussion. No drop outs occurred. An external committee reviewed two adverse events in TAU and 1 adverse event in the AR group. All adverse events were unrelated to the intervention and study procedures.ConclusionsBased on this small pilot study, exercise appeared safe in this sample of youth with persistent symptoms.Competing interestsNone.