Randomization to Treadmill Training Improves Physical and Metabolic Health in Association With Declines in Oxidative Stress in Stroke

ObjectiveTo investigate the effect of aerobic exercise vs control (stretching/balance) on inflammatory and oxidative stress biomarkers in stroke survivors and whether these changes are associated with improvements in physical and metabolic health.DesignRandomized controlled trial.SettingThe general communities of Baltimore, Maryland, and Atlanta, Georgia.ParticipantsTwo hundred forty-six older (>50 years), chronic (>6 months) survivors of stroke (N=246) with hemiparetic gait were recruited, with 51 completing pre-intervention testing and 39 completing postintervention testing. Participants were required to have completed all conventional physical therapy and be capable of walking 3 minutes on a treadmill (N=246).InterventionParticipants completed 6 months of 2 times/wk stretching or balance (ST; n=19) or 3 times/wk aerobic treadmill rehabilitation (TM; n=20;).Main Outcome Measure(s)Peak oxygen uptake rate (V?o₂peak), 6-minute walking distance (6MWD), fasting plasma glucose, insulin, oxidative stress, and inflammatory biomarkers were assessed pre- and postintervention. Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) was calculated.ResultsPhysical function and metabolic health parameters tended to improve after TM but not ST (ST vs TM: V?o₂peak: ?9% vs 24%, P<.01; 6MWD: 1% vs 15%, P=.05; insulin: ?1% vs ?31%, P=.05; HOMA-IR: ?3% vs ?29%, P=.06). Plasma concentrations of nitrotyrosine, protein carbonyls, and oxidized low-density lipoprotein (oxLDL) tended to decrease from pre-intervention concentrations in response to TM compared to ST (ST vs TM: nitrotyrosine: 2% vs ?28%, P=.01; protein carbonyls: ?4% vs ?34%, P=.08; oxLDL: ?3% vs ?32%, P<.01). Changes in circulating concentrations of C-reactive protein, protein carbonyls, and oxLDL were negatively associated with changes in V?o₂peak and 6MWD (r's=?0.40 to ?0.76) and positively associated with fasting plasma insulin and HOMA-IR (r's=0.52-0.81, Ps<.01).ConclusionsSix months of TM tends to be associated with increased functional capacity and reduced oxidative stress in chronic stroke survivors. Our findings identify potentially modifiable systemic markers of inflammation and oxidative stress important to stroke rehabilitation and provide potential targets for novel therapeutics in future studies.     

Longer versus shorter daily durations of electrical stimulation during task-specific practice in moderately impaired stroke

Page SJ, Levin L, Hermann V, Dunning K, Levine P. Longer versus shorter daily durations of electrical stimulation during task-specific practice in moderately impaired stroke.ObjectiveTo examine and compare efficacy of 30-, 60-, and 120-minute repetitive task-specific practice (RTP) sessions incorporating use of an electrical stimulation neuroprosthesis (ESN) on affected upper-extremity (UE) movement.DesignProspective, single-blinded, randomized controlled trial.SettingOutpatient rehabilitation hospital.ParticipantsChronic stroke subjects (N=32) exhibiting moderate, stable affected UE motor deficits.InterventionsSubjects participated in 30-, 60-, or 120-minute therapy sessions involving RTP incorporating the ESN, occurring every weekday for 8 weeks. During sessions, they wore the ESNs to enable performance of valued activities that they had identified. A fourth group participated in a 30-minute per weekday home exercise program.Main Outcome MeasuresOutcomes were evaluated using the UE section of the Fugl-Meyer Assessment of Sensorimotor Impairment (FM), the Arm Motor Ability Test (AMAT), the Action Research Arm Test (ARAT), and Box and Block (B&;B) 1 week before and 1 week after intervention.ResultsAfter intervention, subjects in the 120-minute condition were the only ones to exhibit significant score increases on the FM (P=.0007), AMAT functional ability scale (P=.002), AMAT quality of movement scale (P=.0002), and ARAT (P=.02). They also exhibited the largest changes in time to perform AMAT tasks and in B&;B score, but these changes were nonsignificant, (P=.15 and P=.10, respectively).ConclusionsOne hundred and twenty minutes a day of RTP augmented by ESN use elicits the largest and most consistent UE motor changes in moderately impaired stroke subjects.     

Real-World Adherence to OnabotulinumtoxinA Treatment for Spasticity: Insights From the ASPIRE Study

ObjectiveTo identify baseline characteristics and treatment-related variables that affect adherence to onabotulinumtoxinA treatment from the Adult Spasticity International Registry (ASPIRE) study.DesignProspective, observational registry (NCT01930786).SettingInternational clinical sites.ParticipantsAdults with spasticity (N=730).InterventionsOnabotulinumtoxinA at clinician's discretion.Main Outcome MeasuresClinically meaningful thresholds used for treatment adherent (≥3 treatment sessions during 2-year study) and nonadherent (≤2 sessions). Data analyzed using logistic regression and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Treatment-related variables assessed at sessions 1 and 2 only.ResultsOf the total population, 523 patients (71.6%) were treatment adherent with 5.3±1.6 sessions and 207 (28.4%) were nonadherent with 1.5±0.5 sessions. In the final model (n=626/730), 522 patients (83.4%) were treatment adherent and 104 (16.6%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=1.84; CI, 1.06-3.21; P=.030) and use of orthotics (OR=1.88; CI, 1.15-3.08; P=.012). Baseline characteristics associated with nonadherence: history of diplopia (OR=0.28; CI, 0.09-0.89; P=.031) and use of assistive devices (OR=0.51; CI, 0.29-0.90; P=.021). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.43; CI, 0.26-0.72; P=.001) and clinician dissatisfaction with onabotulinumtoxinA to manage pain (OR=0.18; CI, 0.05-0.69; P=.012). Of the population with stroke (n=411), 288 patients (70.1%) were treatment adherent with 5.3±1.6 sessions and 123 (29.9%) were nonadherent with 1.5±0.5 session. In the final stroke model (n=346/411), 288 patients (83.2%) were treatment adherent and 58 (16.8%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=2.99; CI, 1.39-6.44; P=.005) and use of orthotics (OR=3.18; CI, 1.57-6.45; P=.001). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.42; CI, 0.21-0.83; P=.013) and moderate/severe disability on upper limb Disability Assessment Scale pain subscale (OR=0.40; CI, 0.19-0.83; P=.015).ConclusionsThese ASPIRE analyses demonstrate real-world patient and clinical variables that affect adherence to onabotulinumtoxinA and provide insights to help optimize management strategies to improve patient care.     

Crossed Cerebellar Diaschisis Has an Adverse Effect on Functional Outcome in the Subacute Rehabilitation Phase of Stroke: A Case-Control Study

ObjectiveTo investigate whether crossed cerebellar diaschisis (CCD) is associated with functional outcome in the subacute rehabilitation phase of stroke.DesignRetrospective case-control study.SettingHospital-based cohort.ParticipantsThe study enrolled participants who underwent brain single-photon emission computed tomography (N=48). Patients with CCD were identified (n=24). Twenty-four controls were selected for each case-patient by matching age, stroke type (ischemic or hemorrhagic), lesion laterality, and lesion location.InterventionNot applicable.Main Outcome MeasuresThe functional ambulation category (FAC), modified Barthel Index (MBI), and Mini-Mental State Examination (MMSE) were administered at the initial (initiation of rehabilitation therapy) and the follow-up (4wk after rehabilitation therapy) assessments.ResultsThe CCD group had lower MMSE, FAC, MBI, and MMSE scores at the initial assessment (P=.032, .016, and .001, respectively) and lower FAC and MBI scores at the follow-up assessment, than the non-CCD group (P=.001 and .036, respectively). Although CCD was not associated with cognitive impairment, nonambulatory status, and dependent activities of daily living (ADL) at the initial assessment (P=.538, .083, and >.99, respectively), the CCD group had a higher risk of cognitive impairment (adjusted odds ratio [aOR]=4.044; 95% confidence interval [CI], 1.071-15.270; P=.039), nonambulatory status (aOR=7.000; 95% CI, 1.641-29.854; P=.009) and dependent ADL (aOR=13.500; 95% CI, 1.535-118.692; P=.019) at the follow-up assessment.ConclusionsCCD is associated with severe functional impairment and may have an adverse effect on functional outcomes related to cognition, ambulatory function, and ADL during the subacute rehabilitation phase of stroke. This suggests that CCD may be a valuable predictor of functional outcome in the subacute rehabilitation phase of stroke.     

Utilization of Rehabilitation Services in Stroke: A Study Utilizing the Health and Retirement Study With Linked Medicare Claims Data

ObjectivesTo describe Medicare fee-for-service beneficiaries who used poststroke rehabilitation services and identified the strongest predictors of utilization after the initial stroke care episode.DesignPooled, cross-sectional design using data from 1998 to 2010 from the Health and Retirement Study (HRS) with linked Medicare claims data.SettingNA.ParticipantsStroke survivors who were Medicare fee-for-service beneficiaries and participated in the HRS were included (N=515).Main Outcome MeasureUtilization of rehabilitation services up to 10 years poststroke was the primary outcome with logistic regression used to predict utilization. Covariates included demographic factors, baseline functional status, health conditions, personal lifestyle factors, and social support.ResultsRehabilitation service utilization was 21.6%, 6.8%, 15.8%, 16.5%, and <16% in years 2, 4, 6, 8, and 10, respectively. Age was the primary factor predicting use of rehabilitation in the first 10 years poststroke (odds ratio: 1.14; P=.001). Recurrent stroke (odds ratio: 1.64; P=.051) was also significantly associated with utilization, whereas unspecified incident stroke at incident trended toward significance (odds ratio: 2.17; P=.077). None of the other factors was a significant predictor of participation in rehabilitation services in this period.ConclusionA small number of Medicare fee-for-service beneficiaries who are stroke survivors utilize rehabilitation services in the first 10 years poststroke. Of those who do, age is the primary driver of utilization. We analyzed a multitude of factors that might influence utilization, but other factors not available in these data also need to be explored.     

Upper Limb Energy Demand During Unilateral Arm Crank Submaximal Exercise Testing in Individuals With Chronic Stroke

ObjectiveTo investigate upper limb (UL) energy demand during unilateral arm crank submaximal exercise testing in individuals with stroke compared with healthy controls and the relationship between UL energy demand and UL activity in individuals with stroke.DesignCross-sectional, observational study.SettingResearch laboratory.ParticipantsIndividuals with chronic stroke (n=14) and controls (n=12), matched for age, sex, and body mass index (N=26).InterventionsNot applicable.Main Outcome MeasuresUL energy demand was measured as peak oxygen consumption (V̇o₂)/peak load during unilateral arm crank submaximal exercise testing. UL activity was measured using the Box and Block Test (BBT) and Grooved Pegboard Test (GPT).ResultsThe energy demand of the paretic side compared with the nonparetic side of the stroke group was 0.43 mL/kg/min/W (95% confidence interval, 0.03-0.83, P=.005) greater than the dominant compared with the nondominant side of the control group. The median difference between sides in peak V̇o₂/peak load was 52% for the group with stroke compared with 11% for the control group. Positive correlations between the median percentage difference between the paretic and the nonparetic side of peak V̇o₂/peak load and BBT were 0.72 (P=.004) and of V̇o₂/peak load and GPT was 0.77 (P=.002).ConclusionsThe higher energy demand of the paretic UL during unilateral arm crank submaximal exercise testing than the nonparetic and both UL of the controls together with the strong relationship between energy demand and UL activity suggest that the energy demand of the paretic UL has the potential to affect real-life UL activity after stroke.     

Postamputation Cognitive Impairment Is Related to Worse Perceived Physical Function Among Middle-Aged and Older Prosthesis Users

ObjectiveTo compare characteristics between middle-aged and older prosthesis users with and without cognitive impairment and determine whether cognitive impairment contributes to variability in perceived physical function.DesignCross-sectional, observational studySettingGeneral community.ParticipantsAdults 45 years or older, at least 1-year post lower limb amputation (LLA) who were walking independently with a prosthesis (N=119).InterventionNot applicable.Main Outcome MeasuresWe identified cognitive impairment using an education-adjusted Telephone Interview for Cognitive Status-modified score. Perceived physical function was measured using the Prosthesis Mobility Questionnaire.ResultsOf 119 participants (mean age, 62.6±8.2 years; male: 89.1%; vascular etiology: 82.4%; years since amputation: 4.9±4.7 years), 28 (23.5%) had cognitive impairment. Compared with participants without cognitive impairment, those with cognitive impairment were more likely to use an assistive device (60.7% vs 25.3%, P=.002); were older (66.3±7.3 vs 61.5±8.1 years, P=.006) and had more chronic conditions (7.1±3.4 vs 5.4±2.5, P=.004), more depressive symptoms (6.6±5.1 vs 4.2±3.8, P=.008), and worse perceived physical function (2.0±0.6 vs 2.6±0.7, P<.001). Using backward stepwise linear regression, we found that participants with cognitive impairment had worse perceived physical function (standardized parameter estimate [β]=?0.15, P=.02), even after adjusting for depressive symptoms (β=?0.31, P<.001), prosthesis satisfaction (β=0.34, P<.001), number of chronic conditions (β=?0.19, P=.006), and assistive device use (β_cane=0.01, P=.93; β_other=?0.20, P=.003). Together, these variables explained 59% of perceived physical function variability.ConclusionsCognitive impairment is common and associated with worse perceived physical function post LLA, even after controlling for physical and mental health differences. Tailored rehabilitation interventions may be needed to improve perceived physical function in prosthesis users with cognitive impairment.     

Mirror Therapy Enhances Motor Performance in the Paretic Upper Limb After Stroke: A Pilot Randomized Controlled Trial

Objective

To investigate the effectiveness of mirror therapy (MT) combined with bilateral arm training and graded activities to improve motor performance in the paretic upper limb after stroke.

Design

Randomized, controlled, assessor-blinded study.

Setting

Inpatient stroke rehabilitation center of a tertiary care teaching hospital.

Participants

Patients with first-time ischemic or hemorrhagic stroke (N=20), confined to the territory of the middle cerebral artery, occurring <6 months before the commencement of the study.

Intervention

The MT and control group participants underwent a patient-specific multidisciplinary rehabilitation program including conventional occupational therapy, physical therapy, and speech therapy for 5 d/wk, 6 h/d, over 3 weeks. The participants in the MT group received 1 hour of MT in addition to the conventional stroke rehabilitation.

Main Outcome Measures

The Upper Extremity Fugl-Meyer Assessment for motor recovery, Brunnstrom stages of motor recovery for the arm and hand, Box and Block Test for gross manual hand dexterity, and modified Ashworth scale to assess the spasticity.

Results

After 3 weeks of MT, mean change scores were significantly greater in the MT group than in the control group for the Fugl-Meyer Assessment (P=.008), Brunnstrom stages of motor recovery for the arm (P=.003) and hand (P=.003), and the Box and Block Test (P=.022). No significant difference was found between the groups for modified Ashworth scale (P=.647).

Conclusions

MT when combined with bilateral arm training and graded activities was effective in improving motor performance of the paretic upper limb after stroke compared with conventional therapy without MT.     

Effects of High-Intensity Interval Training After Stroke (The HIIT Stroke Study) on Physical and Cognitive Function: A Multicenter Randomized Controlled Trial

ObjectiveTo assess the effects of high-intensity interval training (HIIT) on physical, mental, and cognitive functioning after stroke.DesignThe HIIT Stroke Study was a single-blind, multicenter, parallel-group randomized controlled trial.SettingSpecialized rehabilitation units at 3 Norwegian hospitals.ParticipantsAdult stroke survivors (N=70) 3 months to 5 years after a first-ever stroke. Mean age was 57.6±9.2 years and 58.7±9.2 years in the intervention and control groups, respectively.InterventionsParticipants were randomized to standard care in combination with 4×4 minutes of treadmill HIIT at 85%-95% of peak heart rate or standard care only.OutcomesOutcomes were measured using physical, mental, and cognitive tests and the FIM and Stroke Impact Scale. Linear mixed models were used to analyze differences between groups at posttest and 12-month follow-up.ResultsThe intervention group showed a significant treatment effect (95% confidence interval [CI]) from baseline to posttest on a 6-minute walk test of 28.3 (CI, 2.80-53.77) meters (P=.030); Berg Balance Scale 1.27 (CI, 0.17-2.28) points (P=.025); and Trail Making Test Part B (TMT-B; −24.16 [CI, −46.35 to −1.98] s, P=.033). The intervention group showed significantly greater improvement on TMT-B at the 12-month follow-up (25.44 [CI, −49.01 to −1.87] s, P=.035). The control group showed significantly greater improvement in total Functional Independence Measure score with a treatment effect of −2.37 (CI, −4.30 to −0.44) points (P=.016) at 12-month follow-up. No significant differences were identified between groups on other outcomes at any time point.ConclusionsHIIT combined with standard care improved walking distance, balance, and executive function immediately after the intervention compared with standard care only. However, only TMT-B remained significant at the 12-month follow-up.     

The strength of the ankle dorsiflexors has a significant contribution to walking speed in people who can walk independently after stroke: an observational study

Dorsch S, Ada L, Canning CG, Al-Zharani M, Dean C. The strength of the ankle dorsiflexors has a significant contribution to walking speed in people who can walk independently after stroke: an observational study.ObjectiveTo investigate the relationship between the strength of muscles of the affected lower limb and walking speed after stroke.DesignA cross-sectional observational study.SettingUniversity laboratory.ParticipantsStroke survivors (N=60; mean age ± SD, 69±11y) 1 to 6 years poststroke, able to walk 10m independently without aids.InterventionsNot applicable.Main Outcome MeasuresMaximum isometric strength of 12 muscle groups (hip flexors/extensors, adductors/abductors, internal/external rotators, knee flexors/extensors, ankle dorsiflexors/plantarflexors, invertors/evertors) of the affected lower limb was measured using hand-held dynamometry. Comfortable walking speed was measured using the ten-meter walk test.ResultsUnivariate analysis revealed that strength of the hip flexors (r=.35, P=.01), hip extensors (r=.29, P=.03), hip internal rotators (r=.30, P=.02), hip adductors (r=.29, P=.03), knee extensors (r=.27, P=.03), knee flexors (r=.30, P=.02), ankle dorsiflexors (r=.50, P=.00), ankle plantarflexors (r=.29, P=.03), and ankle evertors (r=.33, P=.01) were all positively associated with walking speed. Multivariate analysis (n=58) revealed that the combined strength of the ankle dorsiflexors and the hip flexors accounted for 34% of the variance in walking speed (P<.001). The ankle dorsiflexors accounted for 31% of the variance (P<.001).ConclusionsThe strength of muscle groups other than the lower limb extensors, particularly the ankle dorsiflexors, has an important role in determining walking speed after stroke.     

High-Intensity Interval Training in Cardiac Rehabilitation: Impact on Fat Mass in Patients With Myocardial Infarction

ObjectiveTo examine the effect of high-intensity interval training (HIIT) on body fat mass and distribution in patients with myocardial infarction (MI) who underwent cardiac rehabilitation (CR).Patients and MethodsWe retrospectively screened 391 consecutive patients with MI enrolled in CR between September 1, 2015, and February 28, 2018. We included 120 patients who completed 36 CR sessions and underwent pretest-posttest dual-energy x-ray absorptiometry; 90 engaged in HIIT, and 30 engaged in moderate-intensity continuous training (MICT). High-intensity interval training included 4 to 8 alternating intervals of high- (30-60 seconds at a rating of perceived exertion [RPE] of 15-17 [Borg scale range, 6-20]) and low-intensity (1-5 minutes at RPE <14), and MICT performed for 20 to 45 minutes of exercise at an RPE of 12 to 14. Body weight, fat mass, and lean mass were measured via dual-energy x-ray absorptiometry with lipid profile measured via clinical procedures.ResultsThe HIIT and MICT groups were similar in age (67 vs 67 years), sex (26.7% [24 of 90 patients in the HIIT group] vs 26.7% [8 of 30 in the MICT group), and body mass index (30.3 vs 29.5 kg/m²) at baseline. The HIIT group had greater reductions in body fat percentage (P<.001), fat mass (P<.001), abdominal fat percentage (P<.001), waist circumference (P=.01), total cholesterol (P=.002), low-density lipoprotein cholesterol (P<.001), and triglycerides (P=.006). Improvements in total body mass and body mass index were not different across groups. After matching exercise duration, exercise intensity, and energy expenditure, HIIT-induced improvements in total fat mass (P=.02), body fat percentage (P=.01), and abdominal fat percentage (P=.02) persisted.ConclusionOur data suggest that supervised HIIT results in significant reductions in total fat mass (P<.001) and abdominal fat percentage (P<.001) and improved lipid profile in patients with MI who undergo CR.     

Different level, but a similar day pattern of physical activity in workers and sick-listed people with chronic nonspecific musculoskeletal pain

Reneman MF, de Vries HJ, van den Hengel EJ, Brouwer S, van der Woude LH. Different level, but a similar day pattern of physical activity in workers and sick-listed people with chronic nonspecific musculoskeletal pain.ObjectiveTo investigate whether physical activity (PA) levels and day patterns of sick-listed workers with chronic nonspecific musculoskeletal pain (CMP) admitted for multidisciplinary rehabilitation are different from those of workers with CMP.DesignCross-sectional.SettingOutpatient rehabilitation center and general community.ParticipantsA convenience sample of sick-listed patients with CMP (n=27) referred for multidisciplinary pain rehabilitation, and a volunteer sample of workers with CMP (n=107; <5% sick leave in year before participation).InterventionParticipants wore an accelerometer for 5 to 7 consecutive days.Main Outcome MeasurePA, expressed as activity counts. All analyses were corrected for confounders.ResultsPA levels of workers with CMP were higher than those of sick-listed patients (P=.01). After correction for confounders, work status explained 3.5% of the variance observed in activity counts (F_change=5.27, P=.024). In the mornings, group status significantly contributed to the variance in mean activity counts (F_change=5.32, P=.02). In afternoons (F_change=3.29, P=.07) and evenings (F_change=2.41, P=.12), the effect of group status on PA level was nonsignificant. No significant interaction was observed between time and group status (Wilks' λ=.92, F_14,104=.66, P=.80).ConclusionsWorkers with CMP have a higher PA level compared with sick-listed patients. The PA day pattern did not differ significantly between the 2 groups.     

Prognostic Significance of Holter Monitor Findings in Patients With Light Chain Amyloidosis

Objective

To evaluate the prognostic impact of Holter findings in patients with light chain amyloidosis.

Contribution of ankle dorsiflexor strength to walking endurance in people with spastic hemiplegia after stroke

Ng SS, Hui-Chan CW. Contribution of ankle dorsiflexor strength to walking endurance in people with spastic hemiplegia after stroke.Objectives(1) To determine the relationships of ankle dorsiflexor strength, ankle plantarflexor strength, and spasticity of the ankle plantarflexors with walking endurance; (2) to determine whether affected ankle dorsiflexor strength makes an independent contribution to walking endurance; and (3) to quantify its relative contribution to the walking endurance of people with spastic hemiplegia after stroke.DesignA cross-sectional study.SettingUniversity-based rehabilitation center.ParticipantsSubjects (N=62) with spastic hemiplegia.InterventionsNot applicable.Main Outcome MeasuresWalking endurance was measured by the distance covered in the six-minute walk test (6MWT). Ankle dorsiflexor and plantarflexor strength were measured using a load-cell mounted on a custom-built foot support. Plantarflexor spasticity was measured using the Composite Spasticity Scale.ResultsThe six-minute walk distances showed stronger positive correlation with affected dorsiflexor strength (r=.793, P≤.000) when compared with affected plantarflexor strength (r=.349, P=.005). Results of the regression model showed that after adjusting for basic demographic and stroke-related impairments, affected ankle dorsiflexor strength remained independently associated with six-minute walk distance, accounting for 48.8% of the variance.ConclusionsThis is the first study, to our knowledge, to document the importance of ankle dorsiflexor strength as an independent determinant of walking endurance in stroke survivors with spastic plantarflexors. Our findings suggest that stroke rehabilitation programs aiming to improve walking endurance should include strengthening exercises for the ankle dorsiflexors.     

Cardiac Amyloidosis Without Increased Left Ventricular Wall Thickness

ObjectivesTo determine how often left ventricular wall thickness (LVWT) is normal and to assess the effect of LVWT on clinical outcomes of patients with immunoglobulin light chain (AL) cardiac amyloidosis.Patients and MethodsA total of 117 patients with systemic AL amyloidosis were retrospectively categorized from April 1, 1995, to September 15, 2012; group A included cardiac amyloidosis patients with an LVWT greater than 12 mm (45 patients); group B, cardiac amyloidosis patients with an LVWT of 12 mm or less (25 patients); and group C, no evidence of cardiac amyloidosis (47 patients). We compared echocardiographic parameters and survival rates among the 3 groups.ResultsNo differences were found between groups A and B in the following parameters: left ventricular ejection fraction (median, 56% [interquartile range (IQR), 46%-63%] vs 56% [IQR, 49%-63%], P=.76), left arterial volume index (median, 44.5 [IQR, 38.5-59.7] vs 43.9 [IQR, 33.8-57.1] mL/m², P=.79), eˈ (median, 0.04 [IQR, 0.03-0.05] vs 0.05 [IQR, 0.04-0.06] m/s, P=.10), and E/eˈ (early diastolic mitral inflow velocity (E)/eˈ) (median, 18.4 [IQR, 12.0-23.3] vs 18.0 [IQR, 13.6-25.0], P=.98). Patients in group C exhibited significantly different values for these parameters (median, 65% [IQR, 61%-69%], 23.4 [IQR, 18.0-29.0] mL/m², 0.08 [IQR, 0.06-0.09] m/s, and 8.8 [IQR, 7.2-10.5], respectively; all P<.001). The survival rates were statistically different, with median survival times of 422, 729, and 2080 days in groups A, B, and C, respectively (P=.002). Using multivariate Cox proportional hazards regression analysis, we found that age, an N-terminal pro–B-type natriuretic peptide level of 1800 pg/mL or greater, E/eˈ, and complete hematologic remission were significant predictors of survival.ConclusionsA third of patients with AL cardiac amyloidosis were diagnosed as having an LVWT of 12 mm or less. Because appropriate therapy can improve the survival of patients with AL cardiac amyloidosis, early detection by sensitive diagnostic methods should be pursued even when LVWT is not increased.     

Changes in balance and walking from stroke rehabilitation to the community: a follow-up observational study

Blennerhassett JM, Dite W, Ramage ER, Richmond ME. Changes in balance and walking from stroke rehabilitation to the community: a follow-up observational study.ObjectivesTo investigate (1) whether clinical test scores at discharge predict falls or limited community mobility after discharge from inpatient stroke rehabilitation; and (2) how walking and dynamic standing balance change after discharge.DesignFollow-up observational study between 6 and 36 months after discharge.SettingRehabilitation setting.ParticipantsCommunity-dwelling stroke survivors (N=30) who could walk unassisted when discharged from inpatient rehabilitation.InterventionsNot applicable.Main Outcome MeasuresSix-minute walk test (6MWT), Four Square Step Test (FSST), Step Test (ST), Environmental Analysis of Mobility Questionnaire (EAMQ), Falls Efficacy Scale–International (FES-I), and self-reported falls.ResultsFollow-up occurred at a median of 14.5 months postdischarge. Significant improvements occurred between discharge and follow-up for the 6MWT (mean difference [MD]=110.1m; 95% confidence interval [CI], 70.8–149.4; P<.001), ST (MD=1.8 steps; 95% CI, 0.3–3.4; P=.03), and FSST (MD=4.3s; 95% CI, ?10.3 to 1.6; P=.05). Despite this, 40% of participants reported falling. The group who fell had lower clinical test scores at discharge and follow-up than nonfallers. Specific cutoff scores for the clinical tests accurately classified falls history in 70% to 78% of participants. The cutoff scores were <250m for the 6MWT, <10 steps on the ST, and a failure or ≥15 seconds to complete the FSST. Participants performing under the cutoff scores reported lower levels of community mobility (EAMQ, P<.04). Concern about falling was only higher for those classified at risk by the FSST (FES-I, P=.008).ConclusionsThe FSST, ST, and 6MWT scores at discharge had good falls prediction. People classified at risk of falls avoided more tasks in their home and community than those not classified at risk.     

Predictors of Outpatient Pulmonary Rehabilitation Uptake,Adherence, Completion,and Treatment Response Among Male U.S. Veterans With Chronic Obstructive Pulmonary Disease

ObjectiveTo examine predictors of uptake (never start), adherence (drop out), and completion of pulmonary rehabilitation (PR), as well as PR treatment response based on minimal clinically important difference (MCID) on the 6-minute walk test (6MWT) distance and Chronic Respiratory Questionnaire–Self-Report (CRQ-SR).DesignRetrospective, cohort study.SettingVeterans Health Administration.ParticipantsU.S. veterans with chronic obstructive pulmonary disease (COPD) (N=253) referred to PR between 2010 and 2018.InterventionsOutpatient PR program.Main Outcome MeasuresParticipants completed baseline (time 1) measures of depression (Beck Depression Inventory-II), health-related quality of life (CRQ-SR), self-efficacy (Exercise Self-Regulatory Efficacy Scale [Ex-SRES]), and COPD knowledge. Exercise capacity was assessed with the 6MWT. Participants who completed all 18 sessions of PR repeated assessments (time 2). Logistic regression models examined predictors of uptake, adherence, and completion of PR as well as treatment response based on MCID.ResultsParticipants were referred to PR with 24.90% never starting, 28.90% dropping out, and 46.20% completing. No differences emerged between never starters and dropouts. Having a history of any cancer increased the likelihood of completing PR (vs never starting; odds ratio [OR], 3.18; P=.003). Greater CRQ-SR dyspnea score, indicating less dyspnea, was associated with increased likelihood of completing PR (OR, 1.12; P=.006). Past smoking compared with current smoking was associated with increased likelihood of completion (OR, 3.89; P≤.002). Those without a history of alcohol use disorder had increased likelihood of completing PR (OR, 2.23; P=.048). Greater baseline 6MWT distance was associated with lower likelihood of achieving MCID in 6MWT (OR, 0.99; P<.001). Greater Ex-SRES was associated with decreased likelihood of achieving 6MWT MCID (OR, 0.98; P=.023).ConclusionsFindings suggest that early psychoeducation on dyspnea management and smoking and alcohol cessation may increase completion of PR.     

Unilateral Strength Training of the Less Affected Hand Improves Cortical Excitability and Clinical Outcomes in Patients With Subacute Stroke: A Randomized Controlled Trial

ObjectivesTo investigate whether unilateral strength training helps improve cortical excitability and clinical outcomes after stroke.DesignRandomized controlled trial.SettingRehabilitation sciences research center.ParticipantsPatients with subacute stroke (N=26) were randomly assigned to a control group (n=13) or the experimental group (n=13).InterventionsParticipants in both groups received conventional physiotherapy. The experimental group also received unilateral strength training of the less affected wrist extensors. Interventions were applied for 4 weeks (12 sessions, 3 d/wk).Main Outcome MeasuresCortical excitability in both the ipsilesional hemisphere (ipsiH) and contralesional hemisphere (contraH) was assessed by measuring resting motor threshold (RMT), active motor threshold (AMT), motor evoked potential (MEP), and cortical silent period (CSP) at baseline and after the 4-week intervention period. Clinical outcomes were obtained by evaluating wrist extension strength in both the more affected and less affected hands, upper extremity motor function, activities of daily living (ADL), and spasticity.ResultsThe experimental group showed greater MEP amplitude (P=.001) in the ipsiH and shorter CSP duration in both the ipsiH (P=.042) and contraH (P=.038) compared with the control group. However, the reductions in RMT and AMT in both hemispheres were not significantly different between groups. Improvements in wrist extension strength in the more affected (P=.029) and less affected (P=.001) hand, upper extremity motor function (P=.04), and spasticity (P=.014) were greater in the experimental group. No significant difference in ADLs was detected between groups.ConclusionsA combination of unilateral strength training and conventional physiotherapy appears to be a beneficial therapeutic modality for improving cortical excitability and some clinical outcomes in patients with stroke.     

Abstract 20: Rehabilitation outcome for patients requiring percutaneous endoscopic gastrostomy after stroke: a case-matched control study.

Objective: To test the hypothesis that percutaneous endoscopic gastrostomy (PEG) placement, while signaling an increased risk of medical complications and death, allows survivors to achieve functional recovery and home discharge rates similar to those of case-matched controls. Design: Retrospective case-matched control study. Setting: Acute stroke rehabilitation inpatient unit. Participants: 364 patients admitted for stroke rehabilitation, 182 with PEG tubes in place and 182 case controls without PEG were matched at the time of admission for sex, age, FIM™ instrument score (mean, 2.5), and interval poststroke (mean, 1.5d). Interventions: Not applicable. Main Outcome Measures: Outcomes of interest were change in FIM scores, length of rehabilitation hospital stay, need for intercurrent transfer back to the acute hospital, final discharge destination, and survival status. All data were recorded concurrently in a computerized stroke rehabilitation data bank by rehabilitation team members unaware of the study hypothesis. Statistical analyses were as follows: the Student t test for linear data, Mann-Whitney U test for ordinal data, the chi-square test for categorical data. Variances are provided as mean ± SEM. Results: Outcomes for the 2 groups, PEG versus controls, respectively, were as follows: change in FIM scores from admission to discharge (17.3±1.3 vs 20.5±1.2, P=.07); length of rehabilitation hospital stay (45.4±1.8d vs 44.1±1.5d, P=.57); need for intercurrent transfer back to the acute hospital (51/182 vs 22/182, P=.0001); final discharge destination home/institutional care (92/74 vs 97/80, P=.91); and survival status dead/alive (16/166 vs 5/177, P=.01). Conclusions: Patients who require PEG placement are at increased risk for medical complications and death. Those who survive, however, show similar functional recovery and rate of home discharge as case-matched controls.