Stroke rehabilitation reaches a threshold

Motor training with the upper limb affected by stroke partially reverses the loss of cortical representation after lesion and has been proposed to increase spontaneous arm use. Moreover, repeated attempts to use the affected hand in daily activities create a form of practice that can potentially lead to further improvement in motor performance. We thus hypothesized that if motor retraining after stroke increases spontaneous arm use sufficiently, then the patient will enter a virtuous circle in which spontaneous arm use and motor performance reinforce each other. In contrast, if the dose of therapy is not sufficient to bring spontaneous use above threshold, then performance will not increase and the patient will further develop compensatory strategies with the less affected hand. To refine this hypothesis, we developed a computational model of bilateral hand use in arm reaching to study the interactions between adaptive decision making and motor relearning after motor cortex lesion. The model contains a left and a right motor cortex, each controlling the opposite arm, and a single action choice module. The action choice module learns, via reinforcement learning, the value of using each arm for reaching in specific directions. Each motor cortex uses a neural population code to specify the initial direction along which the contralateral hand moves towards a target. The motor cortex learns to minimize directional errors and to maximize neuronal activity for each movement. The derived learning rule accounts for the reversal of the loss of cortical representation after rehabilitation and the increase of this loss after stroke with insufficient rehabilitation. Further, our model exhibits nonlinear and bistable behavior: if natural recovery, motor training, or both, brings performance above a certain threshold, then training can be stopped, as the repeated spontaneous arm use provides a form of motor learning that further bootstraps performance and spontaneous use. Below this threshold, motor training is "in vain": there is little spontaneous arm use after training, the model exhibits learned nonuse, and compensatory movements with the less affected hand are reinforced. By exploring the nonlinear dynamics of stroke recovery using a biologically plausible neural model that accounts for reversal of the loss of motor cortex representation following rehabilitation or the lack thereof, respectively, we can explain previously hard to reconcile data on spontaneous arm use in stroke recovery. Further, our threshold prediction could be tested with an adaptive train-wait-train paradigm: if spontaneous arm use has increased in the "wait" period, then the threshold has been reached, and rehabilitation can be stopped. If spontaneous arm use is still low or has decreased, then another bout of rehabilitation is to be provided.     

Shoulder and elbow muscle activity during fully supported trajectory tracking in people who have had a stroke

An inability to perform tasks involving reaching is a common problem for stroke patients. This paper provides an insight into mechanisms associated with recovery of upper limb function by examining how stroke participants’ upper limb muscle activation patterns differ from those of neurologically intact participants, and how they change in response to an intervention.In this study, five chronic stroke participants undertook nine tracking tasks in which trajectory (orientation and length), speed and resistance to movement were varied. During these tasks, EMG signals were recorded from triceps, biceps, anterior deltoid, upper, middle and lower trapezius and pectoralis major. Data collection was performed in sessions both before, and after, an intervention in which participants performed a similar range of tracking tasks with the addition of responsive electrical stimulation applied to their triceps muscle. The intervention consisted of eighteen one hour treatment sessions, with two participants attending an additional seven sessions. During all sessions, each participant’s arm was supported by a hinged arm-holder which constrained their hand to move in a two dimensional plane.Analysis of the pre intervention EMG data showed that timing and amplitude of peak EMG activity for all stroke participants differed from neurologically intact participants. Analysis of post intervention EMG data revealed that statistically significant changes in these quantities had occurred towards those of neurologically intact participants.     

Comparing unilateral and bilateral upper limb training: The ULTRA-stroke program design

Background  

About 80% of all stroke survivors have an upper limb paresis immediately after stroke, only about a third of whom (30 to 40%) regain some dexterity within six months following conventional treatment programs. Of late, however, two recently developed interventions - constraint-induced movement therapy (CIMT) and bilateral arm training with rhythmic auditory cueing (BATRAC) - have shown promising results in the treatment of upper limb paresis in chronic stroke patients. The ULTRA-stroke (acronym for Upper Limb TRaining After stroke) program was conceived to assess the effectiveness of these interventions in subacute stroke patients and to examine how the observed changes in sensori-motor functioning relate to changes in stroke recovery mechanisms associated with peripheral stiffness, interlimb interactions, and cortical inter- and intrahemispheric networks. The present paper describes the design of this single-blinded randomized clinical trial (RCT), which has recently started and will take several years to complete.     

The effect of long-term homocysteine-lowering on carotid intima-media thickness and flow-mediated vasodilation in stroke patients: a randomized controlled trial and meta-analysis

Background

Experimental and epidemiological evidence suggests that homocysteine (tHcy) may be a causal risk factor for atherosclerosis. B-vitamin supplements reduce tHcy and improve endothelial function in short term trials, but the long-term effects of the treatment on vascular structure and function are unknown.

Methods

We conducted a sub-study of VITATOPS, a randomised, double-blind, placebo-controlled intervention trial designed to test the efficacy of long term B-vitamin supplementation (folic acid 2 mg, vitamin B₆ 25 mg and vitamin B₁₂ 0.5 mg) in the prevention of vascular events in patients with a history of stroke. We measured carotid intima-medial thickness (CIMT) and flow-mediated dilation (FMD) at least two years after randomisation in 162 VITATOPS participants. We also conducted a systematic review and meta-analysis of studies designed to test the effect of B-vitamin treatment on CIMT and FMD.

Results

After a mean treatment period of 3.9 ± 0.9 years, the vitamin-treated group had a significantly lower mean plasma homocysteine concentration than the placebo-treated group (7.9 μmol/L, 95% CI 7.5 to 8.4 versus 11.8 μmol/L, 95% CI 10.9 to 12.8, p < 0.001). Post-treatment CIMT (0.84 ± 0.17 mm vitamins versus 0.83 ± 0.18 mm placebo, p = 0.74) and FMD (median of 4.0%, IQR 0.9 to 7.2 vitamins versus 3.0%, IQR 0.6 to 6.6 placebo, p = 0.48) did not differ significantly between groups. A meta-analysis of published randomised data, including those from the current study, suggested that B-vitamin supplements should reduce CIMT (-0.10 mm, 95% CI -0.20 to -0.01 mm) and increase FMD (1.4%, 95% CI 0.7 to 2.1%). However, the improvement in endothelial function associated with homocysteine-lowering treatment was significant in short-term studies but not in longer trials.

Conclusion

Although short-term treatment with B-vitamins is associated with increased FMD, long-term homocysteine-lowering did not significantly improve FMD or CIMT in people with a history of stroke.

Trial Registration

Clinical Trial Registration URL: http://www.actr.org.au/ Trial Registration number: 12605000005651     

强制性运动疗法在脑卒中偏瘫康复治疗中的应用效果研究

目的:研究强制性运动疗法(CIMT)在脑卒中偏瘫康复治疗中的应用效果。方法:将100例脑卒中偏瘫患者随机分为两组,对照组50例予常规运动疗法,实验组50例予CIMT。治疗后,比较两组患者的临床总有效率、步行速度评分、日常生活活动能力评分、运动功能评分及患者满意度。结果:治疗后,试验组的总有效率显著高于对照组(90%vs.68%),步行速度评分[(61.25±7.94)vs.46.12±8.56]、日常生活活动能力评分[(58.76±8.92)vs.47.95 9.16]、运动功能评分[(85.14±4.68)vs.52.39 9.64]、患者满意度(94%vs.78%)较对照组均明显升高(94%vs.78%),差异具有统计学意义(P0.05)。结论:强制性运动疗法用于脑卒中偏瘫患者康复治疗的临床效果明显提升,可有效改善患者的运动功能。     

Residual Upper Arm Motor Function Primes Innervation of Paretic Forearm Muscles in Chronic Stroke after Brain-Machine Interface (BMI) Training

Background

Abnormal upper arm-forearm muscle synergies after stroke are poorly understood. We investigated whether upper arm function primes paralyzed forearm muscles in chronic stroke patients after Brain-Machine Interface (BMI)-based rehabilitation. Shaping upper arm-forearm muscle synergies may support individualized motor rehabilitation strategies.

Methods

Thirty-two chronic stroke patients with no active finger extensions were randomly assigned to experimental or sham groups and underwent daily BMI training followed by physiotherapy during four weeks. BMI sessions included desynchronization of ipsilesional brain activity and a robotic orthosis to move the paretic limb (experimental group, n = 16). In the sham group (n = 16) orthosis movements were random. Motor function was evaluated with electromyography (EMG) of forearm extensors, and upper arm and hand Fugl-Meyer assessment (FMA) scores. Patients performed distinct upper arm (e.g., shoulder flexion) and hand movements (finger extensions). Forearm EMG activity significantly higher during upper arm movements as compared to finger extensions was considered facilitation of forearm EMG activity. Intraclass correlation coefficient (ICC) was used to test inter-session reliability of facilitation of forearm EMG activity.

Results

Facilitation of forearm EMG activity ICC ranges from 0.52 to 0.83, indicating fair to high reliability before intervention in both limbs. Facilitation of forearm muscles is higher in the paretic as compared to the healthy limb (p<0.001). Upper arm FMA scores predict facilitation of forearm muscles after intervention in both groups (significant correlations ranged from R = 0.752, p = 0.002 to R = 0.779, p = 0.001), but only in the experimental group upper arm FMA scores predict changes in facilitation of forearm muscles after intervention (R = 0.709, p = 0.002; R = 0.827, p<0.001).

Conclusions

Residual upper arm motor function primes recruitment of paralyzed forearm muscles in chronic stroke patients and predicts changes in their recruitment after BMI training. This study suggests that changes in upper arm-forearm synergies contribute to stroke motor recovery, and provides candidacy guidelines for similar BMI-based clinical practice.     

Immediate constraint-induced movement therapy causes local hyperthermia that exacerbates cerebral cortical injury in rats

Constraint-induced movement therapy (CIMT), which involves restraint of the nonimpaired arm coupled with physiotherapy for the impaired arm, lessens impairment and disability in stroke patients. Surprisingly, immediate ipsilateral forelimb immobilization exacerbates brain injury in rats. We tested whether immediate ipsilateral restraint for 7 days aggravates injury after a devascularization lesion in rats. Furthermore, we hypothesized that ipsilateral restraint aggravates injury by causing hyperthermia. In experiment 1, each rat received two lesions, one in the motor cortex and one in the visual cortex. Ipsilateral restraint increased only the motor cortex lesion. In additional rats, no differences in core temperature occurred after ipsilateral or contralateral restraint. Thus, ipsilateral restraint does not aggravate injury by a systemic side effect. In experiment 2, we hypothesized that ipsilateral restraint causes hyperthermia in the region surrounding the initial cortical lesion. Brain temperature, measured via telemetry, was significantly higher (approximately 1 degrees C for 24 h) with ipsilateral restraint. A third experiment similarly found that ipsilateral restraint aggravates injury and causes local cortical hyperthermia and that contralateral restraint with externally induced mild hyperthermia aggravates injury. In conclusion, immediate ipsilateral restraint aggravates injury apparently by localized events that include hyperthermia. Caution must be exercised in applying early CIMT to humans, as hyperthermia is detrimental.     

Functional Improvement after Photothrombotic Stroke in Rats Is Associated with Different Patterns of Dendritic Plasticity after G-CSF Treatment and G-CSF Treatment Combined with Concomitant or Sequential Constraint-Induced Movement Therapy

We have previously shown that granulocyte-colony stimulating factor (G-CSF) treatment alone, or in combination with constraint movement therapy (CIMT) either sequentially or concomitantly, results in significantly improved sensorimotor recovery after photothrombotic stroke in rats in comparison to untreated control animals. CIMT alone did not result in any significant differences compared to the control group (Diederich et al., Stroke, 2012;43:185–192). Using a subset of rat brains from this former experiment the present study was designed to evaluate whether dendritic plasticity would parallel improved functional outcomes. Five treatment groups were analyzed (n = 6 each) (i) ischemic control (saline); (ii) CIMT (CIMT between post-stroke days 2 and 11); (iii) G-CSF (10 μg/kg G-CSF daily between post-stroke days 2 and 11); (iv) combined concurrent group (CIMT plus G-CSF) and (v) combined sequential group (CIMT between post-stroke days 2 and 11; 10 μg/kg G-CSF daily between post-stroke days 12 and 21, respectively). After impregnation of rat brains with a modified Golgi-Cox protocol layer V pyramidal neurons in the peri-infarct cortex as well as the corresponding contralateral cortex were analyzed. Surprisingly, animals with a similar degree of behavioral recovery exhibited quite different patterns of dendritic plasticity in both peri-lesional and contralesional areas. The cause for these patterns is not easily to explain but puts the simple assumption that increased dendritic complexity after stroke necessarily results in increased functional outcome into perspective.     

The SNP (rs2230500) in PRKCH decreases the risk of carotid intima-media thickness in a Chinese young adult population

Background

The SNP (rs2230500) in PRKCH (the gene encoding protein kinase C η) is associated with ischemic stroke and cerebral hemorrhage in the Chinese population, but the molecular mechanisms are not clear. The aim of the present study is to investigate the association between the SNP and atherosclerosis that is common pathological basis of ischemic stroke and cerebral hemorrhage.

Methodology/Principal Findings

We examined the associations of the SNP with carotid intima-media thickness (CIMT), atherosclerosis diagnosed by CIMT, and factors related with inflammation in the Beijing Child Blood Pressure Study. A total of 1190 subjects participated in the follow-up study. The SNP was genotyped by allele-specific real-time PCR assay. The SNP (rs2230500) in PRKCH was significantly associated with CIMT (in far wall of left common carotid arteries, P = 0.016; in far wall of right common carotid arteries, P = 0.012) under a recessive model after adjustment for age, gender, smoking, and hypertension. The SNP was also significantly associated with complement C3 (P = 0.012) under a dominant model after adjustment for age, gender, and high sensitivity C-reactive protein.

Conclusions/Significance

Our data provide evidence that the SNP (rs2230500) in PRKCH decreases the risk of CIMT that is a worthwhile predictor of stroke and complement system possibly mediates this process.     

Ebstein's Anomaly: Anatomo-echocardiographic correlation

Background

Carotid intima-media thickness (CIMT) measured by B-mode ultrasonography is a marker of atherosclerosis and is commonly used as an outcome in intervention trials. We have developed DICOM-based software that measures CIMT rapidly on multiple end-diastolic image frames. The aims of this study were to compare the performance of our new software with older bitmap-based CIMT measurement software and to determine whether a ten-fold increase in the number of measurements used to calculate mean CIMT would improve reproducibility.

Methods

Two independent sonographers recorded replicate carotid scans in thirty volunteers and two blinded observers measured CIMT off-line using the new DICOM-based software and older bitmap-based software. A Bland-Altman plot was used to compare CIMT results from the two software programs and t-tests were used to compare analysis times. F-tests were used to compare the co-efficients of variation (CVs) from a standard six-frame measurement protocol with CVs from a sixty-frame measurement protocol. Ordinary least products (OLP) regression was used to test for sonographer and observer biases.

Results

The new DICOM-based software was much faster than older bitmap-based software (average measurement time for one scan 3.4 ± 0.6 minutes versus 8.4 ± 1.8 minutes, p < 0.0001) but CIMT measurements were larger than those made using the alternative software (+0.02 mm, 95%CI 0.01–0.03 mm). The sixty-frame measurement protocol had worse reproducibility than the six-frame protocol (inter-observer CV 5.1% vs 3.5%, p = 0.004) and inter and intra-observer biases were more pronounced in the sixty-frame than the six-frame results.

Conclusion

While the use of DICOM-based software significantly reduced analysis time, a ten-fold increase in the number of measurements used to calculate CIMT did not improve reproducibility. In addition, we found that observer biases caused differences in mean CIMT of a magnitude commonly reported as significant in intervention trials. Our results highlight the importance of good study design with concurrent controls and the need to ensure that no observer drift occurs between baseline and follow-up measurements when CIMT is used to monitor the effect of an intervention.     

Associations between Blood Glucose and Carotid Intima-Media Thickness Disappear after Adjustment for Shared Risk Factors: The KORA F4 Study

Objective

The association between blood glucose and carotid intima-media thickness (CIMT) is considered to be established knowledge. We aimed to assess whether associations between different measures of glycaemia and CIMT are actually independent of anthropometric variables and metabolic risk factors. Moreover, we checked published studies for the adjustment for shared risk factors of blood glucose and CIMT.

Methods

Fasting glucose, 2-hour glucose, HbA1c, and CIMT were measured in 31-81-years-old participants of the population-based Cooperative Health Research in the Region of Augsburg (KORA) F4 study in Southern Germany (n = 2,663). CIMT was assessed according to the Rotterdam protocol. Linear and logistic regression models with adjustment for age, sex, anthropometric measures, hypertension, and dyslipidaemia were fitted to assess the association between continuous measures of glycaemia, and categories of glucose regulation, respectively, with CIMT.

Results

We found a 0.10 mm increase (95%-confidence interval: 0.08–0.12) in CIMT in subjects with compared to subjects without diabetes in crude analysis. This increase was not significant in age-sex adjusted models (p = 0.17). Likewise, neither impaired fasting glucose (p = 0.22) nor impaired glucose tolerance (p = 0.93) were associated with CIMT after adjustment for age, sex, and waist circumference. In multivariable adjusted models, age, sex, hypertension, waist circumference, HDL and LDL cholesterol, but neither fasting glucose nor 2-hour glucose nor HbA1c were associated with elevated CIMT. Literature findings are inconclusive regarding an independent association of glucose levels and CIMT.

Conclusion

CIMT is highly dependent on traditional cardiovascular risk factors, but no relationships between blood glucose and CIMT were found after adjustment for age, sex, and anthropometric variables.     

Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE): a randomized controlled trial protocol

Background

Residual disability after stroke is substantial; 65% of patients at 6 months are unable to incorporate the impaired upper extremity into daily activities. Task-oriented training programs are rapidly being adopted into clinical practice. In the absence of any consensus on the essential elements or dose of task-specific training, an urgent need exists for a well-designed trial to determine the effectiveness of a specific multidimensional task-based program governed by a comprehensive set of evidence-based principles. The Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (ICARE) Stroke Initiative is a parallel group, three-arm, single blind, superiority randomized controlled trial of a theoretically-defensible, upper extremity rehabilitation program provided in the outpatient setting. The primary objective of ICARE is to determine if there is a greater improvement in arm and hand recovery one year after randomization in participants receiving a structured training program termed Accelerated Skill Acquisition Program (ASAP), compared to participants receiving usual and customary therapy of an equivalent dose (DEUCC). Two secondary objectives are to compare ASAP to a true (active monitoring only) usual and customary (UCC) therapy group and to compare DEUCC and UCC.

Methods/design

Following baseline assessment, participants are randomized by site, stratified for stroke duration and motor severity. 360 adults will be randomized, 14 to 106 days following ischemic or hemorrhagic stroke onset, with mild to moderate upper extremity impairment, recruited at sites in Atlanta, Los Angeles and Washington, D.C. The Wolf Motor Function Test (WMFT) time score is the primary outcome at 1 year post-randomization. The Stroke Impact Scale (SIS) hand domain is a secondary outcome measure. The design includes concealed allocation during recruitment, screening and baseline, blinded outcome assessment and intention to treat analyses. Our primary hypothesis is that the improvement in log-transformed WMFT time will be greater for the ASAP than the DEUCC group. This pre-planned hypothesis will be tested at a significance level of 0.05.

Discussion

ICARE will test whether ASAP is superior to the same number of hours of usual therapy. Pre-specified secondary analyses will test whether 30 hours of usual therapy is superior to current usual and customary therapy not controlled for dose.

Trial registration

http://www.ClinicalTrials.gov Identifier: NCT00871715     

Outcome and upper extremity function within 72 hours after first occasion of stroke in an unselected population at a stroke unit. A part of the SALGOT study

Background

Reduced upper extremity function is one of the most common impairments after stroke and has previously been reported in approximately 70-80% of patients in the acute stage. Acute care for stroke has changes over the last years, with more people being admitted to a stroke unit as well as use of thrombolysis. The aim of the present study was to describe baseline characteristics, care pathway and discharge status in an unselected group of patients with first occasion of stroke who were at a stroke unit within 72 hours after stroke and also to investigate the frequency of impaired arm and hand function. A second aim was to explore factors associated with impaired upper extremity function and the impact of impairment on the patient’s outcome.

Methods

Patients over 18 years of age with first ever stroke, living in a geographical catchment area, being at the stroke unit within 72 hours after onset, with no prior upper extremity impairment were included. Baseline characteristics, arm and hand function within 72 hours, stroke outcome and care pathway in the acute phase were described, by gathering information retrospectively from the patients’ charts. Ischemic strokes were categorized according to the Bamford classification and the Trial of Org 10172 in Acute Stroke Treatment criteria.

Results

Of the 969 patients with first ever stroke who were screened, 642 patients fulfilled the inclusion criteria. According to the National Institutes of Health Stroke Scale (NIHSS), the patients had a mean score of 6.0, median 3.0, at arrival to the hospital. Ischemic stroke was most frequent in the anterior circulation (87.7%). Within 72 hours after stroke onset 48.0% of the patients had impaired arm and hand function and this was positively associated with higher age (p?<?0.004), longer stay in the acute care (p?<?0.001) and mortality in acute care (p?<?0.001). Directly admitted to the stroke unit were 89.1% of the patients and 77.1% received hospital care on same day as stroke onset. Mean length of stay in the stroke unit was 9.9 days, 56.8% of the patients were discharged directly home from the stroke unit. Mortality within 72 hours after stroke onset was 5.0%.

Conclusion

Impaired arm and hand function is present in 48% of the patients in a non selected population with first ever stroke, estimated within 72 hours after onset. This is less than previously reported. Impaired arm and hand function early after stroke is associated with higher age, longer stay in the acute care, and higher mortality within the acute hospital care.

     

Oxidative Damage Markers Are Significantly Associated with the Carotid Artery Intima-Media Thickness after Controlling for Conventional Risk Factors of Atherosclerosis in Men

Background

This study aimed to assess the association between oxidative damage markers and carotid artery intima-media thickness (CIMT) after controlling for conventional risk factors of atherosclerosis in multiple logistic regression models.

Methods and Findings

Fifty-one case male participants (CIMT ≥ 0.9 mm) were enrolled during their visits to Korean Genomic Rural Cohort Study of Wonju centers between May 1 and August 31, 2011, along with 51 control participants (CIMT < 0.9 mm) selected using frequency matching by age group. The levels of oxidative damage markers, 8-hydroxy-2′-deoxyquuanosine (8-OHdG), malondialdehyde (MDA), and 8-iso-prostaglandin F2α (Isoprostane), were measured. Conditional logistic regression models were used to evaluate relative relationships between the oxidative damage markers and the risk of high CIMT.

Results

The markers of oxidative lipid (Isoprostane and MDA) and DNA (8-OHdG) damage were associated with CIMT after controlling for the conventional risk factors, including age, low density lipoprotein, body mass index, smoking history, alcohol consumption, and metabolic syndrome (ORs [95% CI] for Isoprostane: 3^rd tertile, 8.47 [2.59-27.67]; for MDA: 3^rd tertile, 8.47 [2.59-27.67]; for 8-OHdG: 3^rd tertile, 5.58 [1.79-17.33]). When all the oxidative damage markers were incorporated in the same logistic regression model, only Isoprostanewas significantly related to CIMT (OR [95% CI]: 4.22 [1.31-13.53] in 2^nd tertile and 14.21 [3.34-60.56] in 3^rd tertile).

Conclusions

In this nested case-control study, the oxidative damage markers of lipid and DNA were associated with CIMT even after controlling for the conventional risk factors of cardiovascular diseases.     

An Open Label Non-inferiority Trial Assessing Vibriocidal Response of a Killed Bivalent Oral Cholera Vaccine Regimen following a Five Year Interval in Kolkata,India

Background

The bivalent killed oral cholera vaccine (OCV) provides 65% cumulative protection over five years. It remains unknown whether a boosting regimen can maintain protection in previously immunized populations. This study examines the immunogenicity and safety of an OCV regimen given five years following initial dosing.

Methodology/Principal Findings

An open label controlled trial was conducted in 426 healthy Indian participants previously enrolled in a large efficacy trial. To assess whether an OCV regimen given after five years can elicit an antibody response equal to that of a primary series, we compared vibriocidal antibody titers in previously immunized participants receiving a two dose booster regimen to participants receiving a primary two dose immunization series. Among participants receiving a two dose primary series of OCV (n = 186), 69% (95% CI 62%-76%) seroconverted. In the intervention arm (n = 184), 66% (95% CI 59%-73%) seroconverted following a two dose boosting schedule given five years following the initial series. Following a single boosting dose, 71% (95% CI 64%-77%) seroconverted. Children demonstrated 79% (95% CI 69%-86%) and 82% (95% CI 73%-88%) seroconversion after primary and boosting regimens, respectively.

Conclusions/Significance

Administration of an OCV boosting regimen elicits an immune response similar to those receiving a primary series in endemic areas. Though a single boosting dose induces a strong immune response, further investigations are needed to measure if these findings translate to clinical protection.     

Effects of cardiovascular exercise early after stroke: systematic review and meta-analysis

ABSTRACT: BACKGROUND: Previous studies have shown the beneficial effects of aerobic exercise in chronic stroke. Most motor and functional recovery occurs in the first months after stroke. Improving cardiovascular capacity may have potential to precipitate recovery during early stroke rehabilitation. Currently, little is known about the effects of early cardiovascular exercise in stroke survivors. The aim of this systematic review was to evaluate the effectiveness of cardiovascular exercise early after stroke. METHODS: A systematic literature search was performed. For this review, randomised and nonrandomised prospective controlled cohort studies using a cardiovascular, cardiopulmonary or aerobic training intervention starting within 6 months post stroke were considered. The PEDro scale was used to detect risk of bias in individual studies. Inter-rater agreement was calculated (kappa). Meta-analysis was performed using a random-effects model. RESULTS: A total of 11 trials were identified for inclusion. Inter-rater agreement was considered to be "very good" (Kappa: 0.81, Standard Error: 0.06, CI95%: 0.70-0.92), and the methodological quality was "good" (7 studies) to "fair" (4 studies). Peak oxygen uptake data were available for 155 participants. Pooled analysis yielded homogenous effects favouring the intervention group (standardised mean difference (SMD) = 0.83, CI95% = 0.50-1.16, Z = 4.93, P < 0.01). Walking endurance assessed with the 6 Minute Walk Test comprised 278 participants. Pooled analysis revealed homogenous effects favouring the cardiovascular training intervention group (SMD = 0.69, CI95% = 0.45-0.94, Z = 5.58, P < 0.01). Gait speed, measured in 243 participants, did not show significant results (SMD = 0.51, CI95% = 0.25-1.26, Z = 1.31, P = 0.19) in favour of early cardiovascular exercise. CONCLUSION: This meta-analysis shows that stroke survivors may benefit from cardiovascular exercise during sub-acute stages to improve peak oxygen uptake and walking distance. Thus, cardiovascular exercise should be considered in sub-acute stroke rehabilitation. However, concepts to influence and evaluate aerobic capacity in severely affected individuals with subacute stroke, as well as in the very early period after stroke, are lacking. Further research is needed to develop appropriate methods for cardiovascular rehabilitation early after stroke and to evaluate long-term effects of cardiovascular exercise on aerobic capacity, physical functioning, and quality-of-life.     

Pre-Bout Standing Body Sway Differs between Adult Boxers Who Do and Do Not Report Post-Bout Motion Sickness

Background

Motion sickness is characterized by subjective symptoms that include dizziness and nausea. Studies have shown that subjective symptoms of motion sickness are preceded by differences in standing body sway between those who experience the symptoms and those who are not. Boxers often report dizziness and nausea immediately after bouts. We predicted that pre-bout standing body sway would differ between boxers who experienced post-bout motion sickness and those who did not.

Methodology/Principal Findings

We collected data on standing body sway before bouts. During measurement of body sway participants performed two visual tasks. In addition, we varied stance width (the distance between the heels). Postural testing was conducted separately before and after participants'' regular warm-up routines. After bouts, we collected self-reports of motion sickness incidence and symptoms. Results revealed that standing body sway was greater after warm-up than before warm-up, and that wider stance width was associated with reduced sway. Eight of 15 amateur boxers reported motion sickness after a bout. Two statistically significant interactions revealed that standing body sway before bouts differed between participants who reported post-bout motion sickness and those who did not.

Conclusions/Significance

The results suggest that susceptibility to motion sickness in boxers may be manifested in characteristic patterns of body sway. It may be possible to use pre-bout data on postural sway to predict susceptibility to post-bout motion sickness.     

Mental practice-based rehabilitation training to improve arm function and daily activity performance in stroke patients: a randomized clinical trial

Background  

Over 50% of patients with upper limb paresis resulting from stroke face long-term impaired arm function and ensuing disability in daily life. Unfortunately, the number of effective treatments aimed at improving arm function due to stroke is still low. This study aims to evaluate a new therapy for improving arm function in sub-acute stroke patients based on mental practice theories and functional task-oriented training, and to study the predictors for a positive treatment result. It is hypothesized that a six-week, mental practice-based training program (additional to regular therapy) targeting the specific upper extremity skills important to the individual patient will significantly improve both arm function and daily activity performance, as well as being cost effective.     

三维旋进式振动疗法联合常规康复训练对脑卒中偏瘫患者上下肢痉挛状态、步行能力及生活质量的影响

摘要 目的：探讨三维旋进式振动疗法联合常规康复训练对脑卒中偏瘫患者上下肢痉挛状态、步行能力及生活质量的影响。方法：按照随机数字表法,将南京医科大学附属苏州医院2020年4月~2022年4月期间收治的80例脑卒中偏瘫患者分为对照组（常规康复训练）和实验组（三维旋进式振动疗法联合常规康复训练）,每组各40例。对比两组偏瘫侧上下肢痉挛状态、步行能力及生活质量情况。结果：两组干预4周后、干预8周后Fugl-Meyer运动功能评分（FMA）上肢、下肢评分均较干预前升高,且实验组高于对照组（P<0.05）。两组干预4周后、干预8周后步长、步速、6 min步行试验（6MWT）均较干预前升高,且实验组高于对照组（P<0.05）。两组干预8周后,生理职能（RP）、活力（VT）、生理功能（PF）、总体健康（GH）、社会功能（SF）、躯体疼痛（BP）、情感职能（RE）、精神健康（MH）均较干预前升高,且实验组高于对照组（P<0.05）。结论：三维旋进式振动疗法联合常规康复训练应用于脑卒中偏瘫患者,可有效改善上下肢痉挛状态,提高步行能力,促进生活质量提高。     

手臂早期重复刺激有助于脑卒中患者运动功能恢复

为了探究脑卒中患者手臂进行重复感觉运动训练后5年的效果,本研究将100名脑卒中患者随机分配到实验组与对照组,进行为期6周的治疗。使用Brunnstrom-Fugl-Meyer (BFM)测试、上肢动作研究(ARA)和Barthel指数(BI)对脑卒中患者进行治疗前、中途和治疗后以及治疗后6个月和12个月评估,并对62位患者治疗后第5年重新评估。第5年随访结果显示,实验组BFM测试和ARA具有显著性差异,从初始评估到第5年评估各组间改善平均差为BFM17分和ARA17.4分,在BI指数中未发现效果。干预治疗对运动缺陷严重的患者治疗效果最佳。卒中急性期对患者手臂进行特定干预措施,对运动功能具有临床意义及长期效应,该结果归功于早期,重复和有针对性的手臂刺激。