Relationship Between Ultrasonographic,Electromyographic, and Clinical Parameters in Adult Stroke Patients With Spastic Equinus: An Observational Study

Objective

To find more accurate indices that could affect decisions in spasticity treatment by investigating the relation between ultrasonographic, electromyographic, and clinical parameters of the gastrocnemius muscle in adults with spastic equinus after stroke.

Design

Observational study.

Setting

University hospitals.

Participants

Chronic patients with stroke with spastic equinus (N=43).

Interventions

Not applicable.

Main Outcome Measures

Ultrasonographic features were spastic gastrocnemius muscle echo intensity, muscle thickness, and posterior pennation angle of the gastrocnemius medialis (GM) and gastrocnemius lateralis (GL) in both legs. Electromyographic evaluation included compound muscle action potentials (CMAPs) recorded from the GM and GL of both legs. Clinical assessment of the spastic gastrocnemius muscle was performed with the Modified Ashworth Scale (MAS) and by measuring ankle dorsiflexion passive range of motion (PROM).

Results

Spastic muscle echo intensity was inversely associated with proximal (GM and GL: P=.002) and distal (GM and GL: P=.001) muscle thickness, pennation angle (GM: P< .001; GL: P=.01), CMAP (GM: P=.014; GL: P=.026), and ankle PROM (GM: P=.038; GL: P=.024). The pennation angle was directly associated with the proximal (GM and GL: P< .001) and distal (GM: P=.001; GL: P< .001) muscle thickness of the spastic gastrocnemius muscle. The MAS score was directly associated with muscle echo intensity (GM: P=.039; GL: P=.027) and inversely related to the pennation angle (GM and GL: P=.001) and proximal (GM: P=.016; GL: P=.009) and distal (GL: P=.006) muscle thickness of the spastic gastrocnemius.

Conclusions

Increased spastic muscle echo intensity was associated with reduced muscle thickness, posterior pennation angle, and CMAP amplitude in the gastrocnemius muscle. Building on previous evidence that these instrumental features are related to botulinum toxin response, these new findings may usefully inform spasticity treatment decisions.     

Exercise Frequency,Health Risk Factors,and Diseases of the Elderly

Objective

To determine the effect of exercise frequency on various diseases and risk factors of the elderly.

Design

Retrospective analysis of a randomized controlled 18-month exercise trial.

Setting

University ambulatory group setting.

Participants

Community-dwelling women aged ≥65 years (N=162) in the area of Northern Bavaria.

Intervention

Mixed, intense aerobic, resistance, and balance protocol for 18 months. Subjects were retrospectively subdivided into 2 groups according to their effective attendance over 18 months (>1–<2 vs ≥2–4 sessions/wk).

Main Outcome Measures

Bone mineral density (BMD), lean body mass, appendicular skeletal muscle mass by dual-energy x-ray absorptiometry, Framingham study-based 10-year coronary heart disease (CHD) risk, and number of falls by calendar method.

Results

Significant differences between the low-frequency exercise group (LF-EG) and the high-frequency exercise group (HF-EG) were observed for lumbar spine BMD (HF-EG, 2.4%±2.8% vs LF-EG, 0.3%±2.2%; P<.001) and proximal femur BMD (HF-EG, 2.4%±2.8% vs LF-EG, −0.5%±1.6%; P=.014), lean body mass (1.6%±3.4% vs 0.3%±2.6%, P=.053), and appendicular skeletal muscle mass (0.9%±4.5% vs −1.3%±3.2%, P=.011). No differences between both exercise groups were observed for 10-year CHD risk (−1.94%±4.14% vs −2.00%±3.13%; P=.943) and number of falls (0.95±1.36 vs 1.03±1.21 falls/person). Comparing the LF-EG with the less active control group (n=47), only nonsignificant effects for fall number (P=.065) and 10-year CHD risk (P=.178) were evaluated.

Conclusions

Although this result might not be generalizable across all exercise types and cohorts, it indicates that an overall exercise frequency of at least 2 sessions/wk may be crucial for impacting bone and muscle mass of elderly subjects.     

Comparison of Intra-articular Hyaluronic Acid Injections With Transcutaneous Electric Nerve Stimulation for the Management of Knee Osteoarthritis: A Randomized Controlled Trial

Objective

To compare the effects of intra-articular hyaluronic acid (HA; ARTZ) and transcutaneous electric nerve stimulation (TENS) in the treatment of patients with knee osteoarthritis.

Design

A prospective, randomized controlled trial.

Setting

Rehabilitation clinic of a teaching hospital.

Participants

Patients with knee osteoarthritis (N=50; aged 51–80y) were randomly assigned to the HA group (n=27) or the TENS group (n=23).

Interventions

The HA group received intra-articular HA injection into the affected knee once a week for 5 consecutive weeks, and the TENS group received a 20- minute session of TENS 3 times a week for 4 consecutive weeks.

Main Outcome Measures

The primary outcome measures used were the visual analog scale (VAS) for pain and the Lequesne index. The secondary outcome measures were range of motion of the knee, walking time, pain threshold, patient global assessment, and disability in activities of daily living. All subjects were assessed at baseline, and at 2 weeks, 2 months, and 3 months after the treatments were completed.

Results

The TENS group exhibited a significantly greater improvement in VAS than the HA group at 2 weeks' follow-up (4.17±1.98 vs 5.31±1.78, respectively; P=.03). In addition, the TENS group also exhibited a significantly greater improvement in the Lequesne index than the HA group at 2 weeks' follow-up (7.78±2.08 vs 9.85±3.54, respectively; P=.01) and at 3 months' follow-up (7.07±2.85 vs 9.24±4.04, respectively; P=.03).

Conclusions

TENS with silver spike point electrodes was observed to be more effective than intra-articular HA injection for patients with knee osteoarthritis in improving the VAS for pain at 2 weeks' follow-up as well as the Lequesne index at 2 weeks' and 3 months' follow-up.     

Plantarflexor Weakness Negatively Impacts Walking in Persons With Multiple Sclerosis More Than Plantarflexor Spasticity

Objectives

To determine whether plantarflexor (PF) spasticity or ankle strength best predicts variance in walking capacity or self-perceived limitations in walking in persons with multiple sclerosis (MS) and whether persons with MS with PF spasticity are weaker and have greater walking dysfunction than do persons with MS without PF spasticity.

Design

Cross-sectional study.

Setting

University research laboratory.

Participants

Forty-two adults with MS (mean age, 42.9±10.1y; Expanded Disability Status Scale score, median=3.0, range=0–6) and 14 adults without disability (mean age, 41.9±10.1y).

Intervention

Not applicable.

Main Outcome Measures

PF spasticity and dorsiflexion and PF maximum voluntary isometric torque were assessed using the modified Ashworth Scale and a computerized dynamometer, respectively. The Timed 25-Foot Walk Test was the primary outcome measure of walking capacity. Secondary measures included the 6-Minute Walk Test and the 12-item Multiple Sclerosis Walking Scale.

Results

PF strength was the most consistent predictor of variance in walking capacity (Timed 25-Foot Walk Test: R² change=.23–.29, P≤.001; 6-Minute Walk Test: R² change=.12–.29, P≤.012), and self-perceived limitations of walking (12-item Multiple Sclerosis Walking Scale: R² change=.04–.14, P<.18). There were no significant differences (P>.05) between persons with MS with PF spasticity and persons with MS without PF spasticity for any of the outcome measures.

Conclusions

Our study suggests a unique contribution of PF weakness to walking dysfunction in persons with MS, and highlights the importance of evaluating PF strength in this clinical population.     

Predictors of Functional Recovery in Patients Admitted to Geriatric Postacute Rehabilitation

Objective

To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation.

Design

Observational study.

Setting

Postacute rehabilitation facility.

Participants

Patients (N=2754) aged ≥65 years admitted over a 4-year period.

Interventions

Not applicable.

Main Outcome Measure

Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement.

Results

Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean ± SD, 63.3±18.0 vs 59.6±24.7) and at discharge (mean ± SD, 86.8±10.4 vs 62.2±22.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]=1.51; 95% confidence interval [CI], 1.16–1.98; P=.003), women (adjusted OR=1.24; 95% CI, 1.01–1.52; P=.045), patients living alone (adjusted OR=1.61; 95% CI, 1.31–1.98; P<.001), and patients without in-home help prior to admission (adjusted OR=1.39; 95% CI, 1.15–1.69; P=.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19–23) and those cognitively intact also had increased odds of functional recovery (adjusted OR=1.56; 95% CI, 1.13–2.15; P=.007; adjusted OR=2.21; 95% CI, 1.67–2.93; P<.001, respectively).

Conclusions

Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome.     

Determining the Activation of Gluteus Medius and the Validity of the Single Leg Stance Test in Chronic,Nonspecific Low Back Pain

Objectives

To determine the activation of the gluteus medius in persons with chronic, nonspecific low back pain compared with that in control subjects, and to determine the association of the clinical rating of the single leg stance (SLS) with chronic low back pain (CLBP) and gluteus medius weakness.

Design

Cohort-control comparison.

Setting

Academic research laboratory.

Participants

Convenience sample of people (n=21) with CLBP (>12wk) recruited by local physiotherapists, and age- and sex-matched controls (n=22). Subjects who received specific pain diagnoses were excluded.

Interventions

Not applicable.

Main Outcome Measures

Back pain using the visual analog scale (mm); back-related disability using the Oswestry Back Disability Index (%); strength of gluteus medius measured using a hand dynamometer (N/kg); SLS test; gluteus medius onset and activation using electromyography during unipedal stance on a forceplate.

Results

Individuals in the CLBP group exhibited significant weakness in the gluteus medius compared with controls (right, P=.04; left, P=.002). They also had more pain (CLBP: mean, 20.50mm; 95% confidence interval [CI], 13.11–27.9mm; control subjects: mean, 1.77mm; 95% CI, −.21 to 3.75mm) and back-related disability (CLBP: mean, 18.52%; 95% CI, 14.46%–22.59%; control subjects: mean, .68%; 95% CI, −.41% to 1.77%), and reported being less physically active. Weakness was accompanied by increased gluteus medius activation during unipedal stance (R=.50, P=.001) but by no difference in muscle onset times. Although greater gluteus medius weakness was associated with greater pain and disability, there was no difference in muscle strength between those scoring positive and negative on the SLS test (right: F=.002, P=.96; left: F=.1.75, P=.19).

Conclusions

Individuals with CLBP had weaker gluteus medius muscles than control subjects without back pain. Even though there was no significant difference in onset time of the gluteus medius when moving to unipedal stance between the groups, the CLBP group had greater gluteus medius activation. A key finding was that a positive SLS test did not distinguish the CLBP group from the control group, nor was it a sign of gluteus medius weakness.     

High-Level Mobility in Chronic Traumatic Brain Injury and Its Relationship With Clinical Variables and Magnetic Resonance Imaging Findings in the Acute Phase

Objectives

To compare high-level mobility in individuals with chronic moderate-to-severe traumatic brain injury (TBI) with matched healthy controls, and to investigate whether clinical variables and magnetic resonance imaging (MRI) findings in the acute phase can predict high-level motor performance in the chronic phase.

Design

A longitudinal follow-up study.

Setting

A level 1 trauma center.

Participants

Individuals (N=136) with chronic TBI (n=65) and healthy matched peers (n=71).

Interventions

Not applicable.

Main Outcome Measures

High-Level Mobility Assessment Tool (HiMAT) and the revised version of the HiMAT performed at a mean of 2.8 years (range, 1.5–5.4y) after injury.

Results

Participants with chronic TBI had a mean HiMAT score of 42.7 (95% confidence interval [CI], 40.2–45.2) compared with 47.7 (95% CI, 46.1–49.2) in the control group (P<.01). Group differences were also evident using the revised HiMAT (P<.01). Acute-phase clinical variables and MRI findings explained 58.8% of the variance in the HiMAT score (P<.001) and 59.9% in the revised HiMAT score (P<.001). Lower HiMAT scores were associated with female sex (P=.031), higher age at injury (P<.001), motor vehicle collisions (P=.030), and posttraumatic amnesia >7 days (P=.048). There was a tendency toward an association between lower scores and diffuse axonal injury in the brainstem (P=.075).

Conclusions

High-level mobility was reduced in participants with chronic, either moderate or severe TBI compared with matched peers. Clinical variables in the acute phase were significantly associated with high-level mobility performance in participants with TBI, but the role of early MRI findings needs to be further investigated. The findings of this study suggest that the clinical variables in the acute phase may be useful in predicting high-level mobility outcome in the chronic phase.     

Pilot Randomized Controlled Trial of Self-Regulation in Promoting Function in Acute Poststroke Patients

Objective

To test the efficacy of self-regulation (SR) for promoting task performance and motor and cognitive functions.

Design

Pilot randomized controlled trial.

Setting

Rehabilitation unit.

Participants

Inpatients with acute poststroke (N=44) after a cerebral infarction aged ≥60 years.

Interventions

Patients were randomly assigned to the SR (n=24) or functional rehabilitation (control; n=20) intervention. The SR intervention consisted of 1 week of therapist-supervised practices of daily tasks using SR of one's own performance (five 1-h sessions). Patients in the control intervention practiced the same daily tasks with a therapist's demonstration and guidance.

Main Outcome Measures

Performance of tasks, including household and monetary transaction tasks; FIM; Fugl-Meyer Assessment (FMA); and Color Trails Test (CTT).

Results

The SR group showed significant improvement in all tasks (median difference, 1–2; effect size [r]=.74–.89) versus none (median difference, 0–0.5) in the control group. Results of the FIM (P<.001, r=.87 in the motor subscale; P<.001, r=.49 in the cognitive subscale), FMA (P<.001, r=.84 for upper extremity motor function and r=.63 for lower extremity motor function), and CTT (P=.002, r=.72) of the SR group improved. The SR group outperformed their control counterparts in 4 of the 5 tasks (median difference, 1; r=.30–.52) and in the FIM motor subscale (P=.002, r=.47), but not in the cognitive subscale and motor and cognitive functions.

Conclusions

SR appears useful for improving task performance that demands both motor and cognitive abilities by promoting information processing and active learning.     

Effects of Physical Exercise on Plasma Levels of Brain-Derived Neurotrophic Factor and Depressive Symptoms in Elderly Women—A Randomized Clinical Trial

Objectives

To investigate the effect of 2 standardized exercise programs, muscle strength exercises (SE) and aerobic exercises (AE), on the plasma levels of brain-derived neurotrophic factor (BDNF) and depressive symptoms in 451 elderly women.

Design

A randomized controlled trial.

Setting

Belo Horizonte/MG–Brazil.

Participants

Community-dwelling older women (N=451; age, 65–89y).

Intervention

The participants were divided into 2 groups: SE and AE. Both protocols lasted 10 weeks, and 30 sessions (1-h sessions) in total were performed 3 times a week under the direct supervision of physical therapists.

Main Outcome Measures

Plasma levels of BDNF (enzyme-linked immunosorbent assay) and depressive symptoms (Geriatric Depression Scale).

Results

There was a significant difference for BDNF plasma levels between the SE and AE groups (P=.009). Post hoc analysis revealed a pre-post intervention difference in BDNF levels only for the SE group (P=.008). A statistically significant difference was found for the pre- and postintervention Geriatric Depression Scale scores in both groups (P=.001), showing that the effects of both exercise protocols were comparable regarding depressive symptoms (P=.185).

Conclusions

The present findings have demonstrated the positive effect of muscle strengthening and aerobic intervention on depressive symptoms in community-dwelling elderly women. Interestingly, only SE significantly increased the plasma levels of BDNF in our sample. The positive effects of physical exercise on depressive symptoms in the elderly were not mediated by BDNF.     

Effects of Repetitive Peripheral Magnetic Stimulation on Upper-Limb Spasticity and Impairment in Patients With Spastic Hemiparesis: A Randomized,Double-Blind,Sham-Controlled Study

Objective

To investigate short-term and long-term effects of repetitive peripheral magnetic stimulation (rpMS) on spasticity and motor function.

Design

Monocentric, randomized, double-blind, sham-controlled trial.

Setting

Neurologic rehabilitation hospital.

Participants

Patients (N=66) with severe hemiparesis and mild to moderate spasticity resulting from a stroke or a traumatic brain injury. The average time ± SD since injury for the intervention groups was 26±71 weeks or 37±82 weeks.

Interventions

rpMS for 20 minutes or sham stimulation with subsequent occupational therapy for 20 minutes, 2 times a day, over a 2-week period.

Main Outcome Measures

Modified Tardieu Scale and Fugl-Meyer Assessment (arm score), assessed before therapy, at the end of the 2-week treatment period, and 2 weeks after study treatment. Additionally, the Tardieu Scale was assessed after the first and before the third therapy session to determine any short-term effects.

Results

Spasticity (Tardieu >0) was present in 83% of wrist flexors, 62% of elbow flexors, 44% of elbow extensors, and 10% of wrist extensors. Compared with the sham stimulation group, the rpMS group showed short-term effects on spasticity for wrist flexors (P=.048), and long-term effects for elbow extensors (P<.045). Arm motor function (rpMS group: median 5 [4–27]; sham group: median 4 [4–9]) did not significantly change over the study period in either group, whereas rpMS had a positive effect on sensory function.

Conclusions

Therapy with rpMS increases sensory function in patients with severe limb paresis. The magnetic stimulation, however, has limited effect on spasticity and no effect on motor function.     

Functional Status Impairment Is Associated With Unplanned Readmissions

Objective

To determine whether functional status on admission to a Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) is associated with unplanned readmission to acute care.

Design

Retrospective cohort study.

Setting

Academic hospital-based CIIRP.

Participants

Consecutive patients (N=1515) admitted to a CIIRP between January 2009 and June 2012.

Interventions

Patients' functional status, the primary exposure variable, was assessed using tertiles of the total FIM score at CIIRP admission, with secondary analyses using the FIM motor and cognitive domains. A propensity score, consisting of 25 relevant clinical and demographic variables, was used to adjust for confounding in the analysis.

Main Outcome Measures

Readmission to acute care was categorized as (1) readmission before planned discharge from the CIIRP, (2) readmission within 30 days of discharge from the CIIRP, and (3) total readmissions from both groups, with total readmissions being the a priori primary outcome.

Results

Among the 1515 patients, there were 347 total readmissions. Total readmissions were significantly associated with FIM scores, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the lowest and middle FIM tertiles versus the highest tertile (AOR=2.6; 95% CI, 1.9–3.7; P<.001 and AOR=1.7; 95% CI, 1.2–2.4; P=.002, respectively). There were similar findings for secondary analyses of readmission before planned discharge from the CIIRP (AOR=3.5; 95% CI, 2.2–5.8; P<.001 and AOR=2.1; 95% CI, 1.3–3.5l P=.002, respectively), and a weaker association for readmissions after discharge from the CIIRP (AOR=1.6; 95% CI, 1.0–2.4; P=.047 and AOR=1.3; 95% CI, 0.8–1.9; P=.28, respectively). The FIM motor domain score was more strongly associated with readmissions than the FIM cognitive score.

Conclusions

Functional status on admission to the CIIRP is strongly associated with readmission to acute care, particularly for motor aspects of functional status and readmission before planned discharge from the CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor.     

Impact of Physical Exercise on Reaction Time in Patients With Parkinson's Disease—Data From the Berlin BIG Study

Objective

To determine whether physical activity may affect cognitive performance in patients with Parkinson's disease by measuring reaction times in patients participating in the Berlin BIG study.

Design

Randomized controlled trial, rater-blinded.

Setting

Ambulatory care.

Participants

Patients with mild to moderate Parkinson's disease (N=60) were randomly allocated to 3 treatment arms. Outcome was measured at the termination of training and at follow-up 16 weeks after baseline in 58 patients (completers).

Interventions

Patients received 16 hours of individual Lee Silverman Voice Treatment-BIG training (BIG; duration of treatment, 4wk), 16 hours of group training with Nordic Walking (WALK; duration of treatment, 8wk), or nonsupervised domestic exercise (HOME; duration of instruction, 1hr).

Main Outcome Measures

Cued reaction time (cRT) and noncued reaction time (nRT).

Results

Differences between treatment groups in improvement in reaction times from baseline to intermediate and baseline to follow-up assessments were observed for cRT but not for nRT. Pairwise t test comparisons revealed differences in change in cRT at both measurements between BIG and HOME groups (intermediate: −52ms; 95% confidence interval [CI], −84/−20; P=.002; follow-up: 55ms; CI, −105/−6; P=.030) and between WALK and HOME groups (intermediate: −61ms; CI, −120/−2; P=.042; follow-up: −78ms; CI, −136/−20; P=.010). There was no difference between BIG and WALK groups (intermediate: 9ms; CI, −49/67; P=.742; follow-up: 23ms; CI, −27/72; P=.361).

Conclusion

Supervised physical exercise with Lee Silverman Voice Treatment-BIG or Nordic Walking is associated with improvement in cognitive aspects of movement preparation.     

Anxiety and Depression Associated With Caregiver Burden in Caregivers of Stroke Survivors With Spasticity

Objective

To investigate the relationship between anxiety/depression and caregiver burden in informal caregivers of stroke survivors with spasticity.

Design

Data were collected via online surveys from informal caregivers 18 years or older who cared for stroke survivors.

Setting

Internet-based survey.

Participants

2007 through 2009 U.S. National Health and Wellness Survey database or Lightspeed Research general panel respondents (N=153).

Interventions

Not applicable.

Main Outcome Measures

Anxiety and depression were self-reported by the caregiver as a physician diagnosis. Depression severity was measured by the Patient Health Questionnaire-9 (PHQ-9). Caregiver burden was measured by the Oberst Caregiving Burden Scale (OCBS) and the Bakas Caregiving Outcomes Scale (BCOS). Logistic regression analyses were conducted with anxiety, depression, and the PHQ-9 depression severity categories as a result of each caregiver burden scale.

Results

Data were analyzed for 153 informal caregivers; they were mostly women (70.6%) and white (78.4%), with a mean age of 51.6 years. For every 1-point increase in the OCBS Difficulty Scale, the odds of anxiety or depression were 2.57 times as great (P<.001) and 1.88 times as great (P=.007), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 2.48 times as great (P<.001). For every 1-point decrease in the BCOS, the odds of anxiety or depression were 2.43 times as great (P<.001) and 2.27 times as great (P=.002), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 4.55 times as great (P<.001).

Conclusions

As caregiver burden increases, caregivers are more likely to have anxiety and depression. Depression severity also increases. Providing treatment to stroke survivors with spasticity that lessens the time and more importantly, the difficulty of caregiving may lead to a reduction in caregiver anxiety and depression.     

Arm-Cranking Exercise Reduced Oxidative Damage in Adults With Chronic Spinal Cord Injury

Objective

To assess the effect of a 12-week arm-cranking exercise program on reducing oxidative damage in untrained adults with chronic spinal cord injury (SCI).

Design

Randomized controlled trial.

Setting

Community-based supervised intervention.

Participants

Male adults with complete SCI at or below the fifth thoracic level (T5) (N=17) volunteered for this study. Participants were randomly allocated to the intervention (n=9) or control (n=8) group using a concealed method.

Intervention

A 12-week arm-cranking exercise program, 3 sessions/wk, consisting of warming-up (10–15min) followed by a main part in arm-crank (20–30min [increasing 2min and 30s every 3wk]) at a moderate work intensity of 50% to 65% of the heart rate reserve (starting at 50% and increasing 5% every 3 weeks) and by a cooling-down period (5–10min).

Main Outcome Measures

Plasmatic levels of total antioxidant status as well as erythrocyte glutathione peroxidase activity were measured. Lipid and protein oxidation were determined as malondialdehyde and carbonyl group levels, respectively. Furthermore, physical fitness and body composition were assessed.

Results

When compared with baseline results, maximum oxygen consumption was significantly increased (P=.031), suggesting an improvement in physical fitness in the intervention group. Regarding the antioxidant defense system, it was found that both total antioxidant status (P=.014) and erythrocyte glutathione peroxidase activity (P=.027) were significantly increased at the end of the training program. As a consequence, plasmatic levels of malondialdehyde (P=.008) and carbonyl groups (P=.022) were significantly reduced.

Conclusion

A 12-week arm-cranking exercise program improved the antioxidant defense system in adults with chronic SCI, which may finally attenuate both lipid and protein oxidation in this population.     

Gabapentinoids Are Effective in Decreasing Neuropathic Pain and Other Secondary Outcomes After Spinal Cord Injury: A Meta-Analysis

Objective

To examine the effectiveness of gabapentin and pregabalin in diminishing neuropathic pain and other secondary conditions in individuals with spinal cord injury (SCI).

Data Sources

A systematic search was conducted using multiple databases for relevant articles published from 1980 to June 2013.

Study Selection

Controlled and uncontrolled trials involving gabapentin and pregabalin for treatment of neuropathic pain, with ≥3 subjects and ≥50% of study population with SCI, were included.

Data Extraction

Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohen's d to calculate standardized mean difference (SMD), SE, and 95% confidence interval (CI) for primary (pain) and secondary outcomes (anxiety, depression, sleep interference) was conducted.

Data Synthesis

Eight studies met inclusion criteria. There was a significant reduction in the intensity of neuropathic pain at <3 months (SMD=.96±.11; 95% CI, .74–1.19; P<.001) and between 3 and 6 months (SMD=2.80±.18; 95% CI, 2.44–3.16; P<.001). A subanalysis found a significant decrease in pain with gabapentin (SMD=1.20±.16; 95% CI, .88–1.52; P<.001) and with pregabalin (SMD=1.71±.13; 95% CI, 1.458–1.965; P<.001). A significant reduction in other SCI secondary conditions, including sleep interference (SMD=1.46±.12; 95% CI, 1.22–1.71; P<.001), anxiety (SMD=1.05±.12; 95% CI, .81–1.29; P<.001), and depression (SMD=1.22±.13; 95% CI, .967–1.481; P<.001) symptoms, was shown. A significantly higher risk of dizziness (risk ratio [RR]=2.02, P=.02), edema (RR=6.140, P=.04), and somnolence (RR=1.75, P=.01) was observed.

Conclusions

Gabapentin and pregabalin appear useful for treating pain and other secondary conditions after SCI. Effectiveness comparative to other analgesics has not been studied. Patients need to be monitored closely for side effects.     

Symptoms of Depression Over Time in Adults With Pediatric-Onset Spinal Cord Injury

Objective

To investigate the prevalence of depressive symptoms in adults with pediatric-onset spinal cord injury (SCI) and explore potential risk factors that may be associated with elevated symptoms.

Design

Longitudinal, cohort survey over a period of 2 to 9 years. Follow-up occurred approximately every year, a total of 868 interviews were conducted, and most participants contributed to at least 3 waves of data (72%; range, 2–8; mean, 4.34±2.16).

Setting

Community.

Participants

Adults (N=214; 133 men; mean age at first interview, 29.52±5.21y; range, 24–42y) who sustained an SCI prior to age 19 (mean age at injury, 13.93±4.37y; range, 0–18y). Participants tended to have complete injuries (71%) and tetraplegia (58%).

Interventions

Not applicable.

Main Outcome Measures

Participants completed measures assessing psychosocial functioning, physical independence, participation, and depression at each time point. Multilevel growth modeling analyses were used to explore depression symptoms across time.

Results

Depression symptoms at initial status were typically minimal (3.07±.24; 95% confidence interval, 2.6–3.54) but fluctuated significantly over time (P<.01). Several factors emerged as significant predictors of depressive symptoms in the final model, including less community participation (P<.01), incomplete injury (P=.02), hazardous drinking (P=.02), bladder incontinence (P=.01), and pain (P=.03). Within individuals, as bowel accidents (P<.01) and pain increased (P<.01), depression scores increased; however, marriage resulted in decreases in depression scores for individuals (P=.02).

Conclusions

These findings suggest that most patients with pediatric-onset SCI are psychologically resilient, but strategies to minimize secondary health complications and foster community participation and engagement should be considered.     

Skill Training for Swallowing Rehabilitation in Patients With Parkinson's Disease

Objective

To examine the effects of skill training on swallowing in individuals with dysphagia secondary to Parkinson's disease (PD) and to explore skill retention after treatment termination.

Design

Within-subject pilot study with follow-up after 2 weeks of treatment and after a 2-week nontreatment period.

Setting

Clinic in a research institute.

Participants

Patients (N=10; mean age, 67.4y) included 3 women (mean Hoehn and Yahr score, 2.6) and 7 men (mean Hoehn and Yahr score, 2.4).

Intervention

Patients underwent 10 daily sessions of skill training therapy focused on increasing precision in muscle contraction during swallowing using visual feedback.

Main Outcome Measures

Data from the timed water swallow test, Test of Mastication and Swallowing Solids, surface electromyography (sEMG) of submental muscles, and swallowing-related quality of life questionnaire were collected at 2 baseline sessions (conducted 2wk apart) at the end of treatment and after 2 nontreatment weeks to assess skill retention.

Results

Immediately after posttreatment, the swallowing rate for liquids (P=.034), sEMG durational parameters of premotor time (P=.003), and preswallow time (P<.001) improved. A functional carryover effect was seen from dry to water swallows (P=.009). Additionally, swallowing-related quality of life improved (P=.018). Reassessment at 2 weeks after treatment termination revealed short-term retention of treatment effects.

Conclusions

A skill-based training approach produced functional, biomechanical, and swallowing-related quality of life improvements in this cohort indicating compelling evidence for the effectiveness of this novel approach for dysphagia rehabilitation in PD.     

Self-Perceived Utilization of the Paretic Arm in Chronic Stroke Requires High Upper Limb Functional Ability

Objective

To explore potential predictors of self-reported paretic arm use at baseline and after task-specific training (TST) in survivors of stroke.

Design

Data were obtained from a randomized controlled trial of somatosensory stimulation and upper limb TST in chronic stroke.

Setting

University laboratory.

Participants

Chronic (≥3mo) survivors of stroke (N=33; mean age, 62y; mean stroke duration, 38mo).

Interventions

Participants received 12 sessions of TST preceded by either active (n=16) or sham (n=17) somatosensory stimulation to all 3 peripheral nerves.

Main Outcome Measures

Demographic and clinical characteristics were entered stepwise into multiple linear regression analyses to determine the factors that best predict baseline Motor Activity Log (MAL) amount of use rating and change 3 months after TST.

Results

The Action Research Arm Test (ARAT) score predicted the amount of use at baseline (R²=.47, P<.001); in using this model, an ARAT score of 54 (maximum of 57) is required to score 2.5 on the MAL (use described as between rarely and sometimes). After TST the change in the ARAT score predicted the change in the amount of use (R²=.31, P=.001). The predictive power of the model for change at 3 months increased if the Fugl-Meyer Assessment wrist component score was added (R²=.41, P=.001).

Conclusions

Utilization of the paretic upper limb in activities of daily living requires high functional ability. The increase in self-reported arm use after TST is dependent on the change in functional ability. These results provide further guidance for rehabilitation decisions.     

Comparative Impacts of Tai Chi,Balance Training,and a Specially-Designed Yoga Program on Balance in Older Fallers

Objective

To compare the effect of a custom-designed yoga program with 2 other balance training programs.

Design

Randomized controlled trial.

Setting

Research laboratory.

Participants

A group of older adults (N=39; mean age, 74.15±6.99y) with a history of falling.

Interventions

Three different exercise interventions (Tai Chi, standard balance training, yoga) were given for 12 weeks.

Main Outcome Measures

Balance performance was examined during pre- and posttest using field tests, including the 8-foot up-and-go test, 1-leg stance, functional reach, and usual and maximal walking speed. The static and dynamic balances were also assessed by postural sway and dynamic posturography, respectively.

Results

Training produced significant improvements in all field tests (P<.005), but group difference and time × group interaction were not detected. For postural sway, significant decreases in the area of the center of pressure with eyes open (P=.001) and eyes closed (P=.002) were detected after training. For eyes open, maximum medial-lateral velocity significantly decreased for the sample (P=.013). For eyes closed, medial-lateral displacement decreased for Tai Chi (P<.01). For dynamic posturography, significant improvements in overall score (P=.001), time on the test (P=.006), and 2 linear measures in lateral (P=.001) and anterior-posterior (P<.001) directions were seen for the sample.

Conclusions

Yoga was as effective as Tai Chi and standard balance training for improving postural stability and may offer an alternative to more traditional programs.     

Botulinum Toxin Dilution and Endplate Targeting in Spasticity: A Double-Blind Controlled Study

Gracies J-M, Lugassy M, Weisz DJ, Vecchio M, Flanagan S, Simpson DM. Botulinum toxin dilution and endplate targeting in spasticity: a double-blind controlled study.

Objective

To determine the effects of botulinum neurotoxin type A (BTX-A) dilution and endplate-targeting in spastic elbow flexors.

Design

Double blind randomized controlled trial; 4-month follow-up after a 160-unit injection of BTX-A into spastic biceps brachii (4 sites). Randomization into: group 1: 100 mouse units (MU)/mL dilution, 0.4cc/site, 4-quadrant injection; group 2: 100MU/mL dilution, 0.4cc/site, 4 sites along endplate band; group 3: 20MU/mL dilution, 2cc/site, 4-quadrant injection (n=7 per group).

Setting

Institutional tertiary care ambulatory clinic.

Participants

Referred sample of 21 adults with spastic hemiparesis. No participant withdrew due to adverse effects.

Intervention

A 160-unit injection of BTX-A of different dilutions and locations into biceps brachii.

Main Outcome Measures

Primary: agonist and antagonist (cocontraction) mean rectified voltage (MRV) of elbow flexors/extensors during maximal isometric flexion/extension; secondary: maximal voluntary power of elbow flexion/extension; spasticity angle and grade in elbow flexors/extensors (Tardieu Scale); active range of elbow extension/flexion.

Results

BTX-A injection overall reduced agonist flexor MRV (-47.5%, P<0.0001), antagonist flexor MRV (-12%, P=.037), antagonist extensor MRV (-19%, P<.01), flexion maximal voluntary power (-33%, P<.001), elbow flexor spasticity angle (-30%, P<.001) and grade (-17%, P=.03), and increased extension maximal voluntary power (24%, P=.037) and active range of elbow extension (5.5%, 8°, P=.002). Agonist and antagonist flexor MRV reductions in group 3 (-81% and -31%) were greater than in groups 1 and 2, whereas increase in active range of elbow extension was greater in group 2 (10%) than in groups 1 and 3 (P<.05, analysis of covariance [ANCOVA]). Elbow flexor spasticity was significantly reduced in groups 2 and 3 only (P<.05, ANCOVA).

Conclusions

In spastic biceps, high-volume or endplate-targeted BTX-A injections achieve greater neuromuscular blockade, cocontraction and spasticity reduction, and active range of elbow extension improvement, than low volume, nontargeted injections.