Synergistic efficacy of repetitive peripheral magnetic stimulation on central intermittent theta burst stimulation for upper limb function in patients with stroke: a double-blinded, randomized controlled trial.

BACKGROUND: Non-invasive techniques such as central intermittent theta burst stimulation (iTBS) and repetitive peripheral magnetic stimulation (rPMS) have shown promise in improving motor function for patients with stroke. However, the combined efficacy of rPMS and central iTBS has not been extensively studied. This randomized controlled trial aimed to investigate the synergistic effects of rPMS and central iTBS in patients with stroke. METHOD: In this study, 28 stroke patients were randomly allocated to receive either 1200 pulses of real or sham rPMS on the radial nerve of the affected limb, followed by 1200 pulses of central iTBS on the ipsilesional hemisphere. The patients received the intervention for 10 sessions over two weeks. The primary outcome measures were the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT). Secondary outcomes for activities and participation included the Functional Independence Measure-Selfcare (FIM-Selfcare) and the Stroke Impact Scale (SIS). The outcome measures were assessed before and after the intervention. RESULTS: Both groups showed significant improvement in FMA-UE and FIM-Selfcare after the intervention (p < 0.05). Only the rPMS + iTBS group had significant improvement in ARAT-Grasp and SIS-Strength and activity of daily living (p < 0.05). However, the change scores in all outcome measures did not differ between two groups. CONCLUSIONS: Overall, the study's findings suggest that rPMS may have a synergistic effect on central iTBS to improve grasp function and participation. In conclusion, these findings highlight the potential of rPMS as an adjuvant therapy for central iTBS in stroke rehabilitation. Further large-scale studies are needed to fully explore the synergistic effects of rPMS on central iTBS. TRIAL REGISTRATION: This trial was registered under ClinicalTrials.gov ID No.NCT04265365, retrospectively registered, on February 11, 2020.

Aesthetic Multiple-Toe Reconstruction With Combined Iliac Bone Graft and Wraparound Free Anterolateral Thigh Flap-A Case Report and Literature Review.

Compared with upper extremity injuries, toe amputations and their replantations are rare because of the difficulty of their relatively thinner soft tissue envelope. Consequently, fewer reconstructive options are available for toes and they are rarely reported in the literature. In this study, we reported a case of right third to fifth toe amputations and their subsequent reconstruction with iliac bone grafts and a free anterolateral thigh flap. After serial debulking and division procedures, 3 toes were divided successfully. Ten months after the initial operation, the patient regained pain-free functional ambulation despite some bone resorption noted on follow-up radiographs. The patient showed high satisfaction on her new toes in terms of aesthetical and functional outcomes. She was able to stand for over 30 minutes without pain. At the 2-year follow-up, the Foot Function Index was 18.3%. Although toe reconstruction is frequently considered unnecessary because of its relative high demand of surgical techniques and little gain on gait; nonetheless, in selected cases, toe reconstruction may still be beneficial if the metatarsophalangeal joints were intact and there is a strong individual desire for aesthetical restoration.

Comparison of motor performance of upper and lower extremities in dual-task tests in patients with mild Alzheimer's dementia.

BACKGROUND: Alzheimer's dementia (AD) is a progressive disease that threatens the self-care and quality of life of elderly people. Early diagnosis and early treatment are crucial. AIM: To examine the difference in executive function of patients with AD by analyzing their performance in gait analysis (Vicon MX system) and a trial making test (TMT) while counting forward or backward. METHODS: Ten elderly persons who had been diagnosed by neurological specialists with mild AD were selected as study participants. Of these patients, 2 were men and 8 were women, and the average age was 74.0 ± 8.6 years. An additional group of 10 elderly persons without AD and matched according to age and sex constituted a control group. RESULTS: The average Mini-Mental State Examination score was 17.7 ± 4.1, and the average clinical dementia rating scale score was 0.8 ± 0.3. We found that backward counting of 3 digits during gait performance in mild AD patients elicited substantial changes in velocity, cadence, coefficient of variation of the stride length, and stride time compared with those of the control group. Regarding upper extremity performance, all TMT tasks were highly sensitive in revealing differences in reaction time between the mild AD group and the control group. DISCUSSION: Dual-task challenges for examining gait parameters and TMT performance can reveal obvious impairment of executive motor function in patients with very mild AD. CONCLUSION: Dual-task motor tests of the upper extremities can be used as screening tools for detecting AD at an early stage.

Aging is associated with increased activities of matrix metalloproteinase-2 and -9 in tenocytes.

BACKGROUND: Most tendon pathology is associated with degeneration, which is thought to involve cyclic loading and cumulative age-related changes in tissue architecture. However, the association between aging and degeneration of the extracellular matrix (ECM) in tendons has not been investigated extensively. METHODS: We examined tenocytes from Achilles tendons taken from rats of three different ages (2, 12, and 24 months). Tenocyte viability was assessed using the 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay. Quantitative real-time polymerase chain reaction (PCR) was used to determine the levels of mRNAs that encode type-I collagen, matrix metalloproteinase (MMP)-2 and -9, tissue inhibitor of metalloproteinase (TIMP)-1 and -2 and transforming growth factor (TGF)-ß1. Gelatin zymography was used to evaluate the enzymatic activities of MMP-2 and -9. Furthermore, the concentration of TGF-ß1 in conditioned medium was evaluated using enzyme-linked immunosorbent assay (ELISA). RESULTS: The results of the MTT assay showed that the number of viable tenocytes decreased with age. No differences were observed in the levels of mRNAs that encode type-I collagen and TGF-ß1 among the three age groups, and the TGF-ß1 concentration did not change with age. However, mRNAs that encode MMP-2 and -9 were significantly more abundant in tenocytes from the aging group, and gelatin zymography revealed that the enzymatic activities of MMP-2 and -9 also increased significantly with age. Furthermore, as compared with young group, mRNAs that encode TIMP-1 and -2 were significantly decreased in tenocytes from the aging group. CONCLUSIONS: Activities of MMP-2 and MMP-9 in tenocytes increase with age. This might provide a mechanistic explanation of how aging contributes to tendinopathy or tendon rupture with age.

Application of Supercharge End-to-Side (SETS) Obturator to Femoral Nerve Transfer in Electrical Injury-Induced Neuropathy to Improve Knee Extension.

Femoral nerve injuries are devastating injuries that lead to paralysis of the quadriceps muscles, weakening knee extension to prohibit ambulation. We report a devastating case of electrical injury-induced femoral neuropathy, where no apparent site of nerve disruption can be identified, thus inhibiting the traditional choices of nerve reconstruction such as nerve repair, grafting, or transfer. Concomitant spinal cord injury resulted in spastic myopathy of the antagonist muscles that further restricted knee extension. Our strategy was to perform (1) supercharge end-to-side technique (SETS) to augment the function of target muscles and (2) fractional tendon lengthening to release the spastic muscles. Dramatic postoperative improvement in passive and active range of motion highlights the effectiveness of this strategy to manage partial femoral nerve injuries.

Kinematic features of rear-foot motion using anterior and posterior ankle-foot orthoses in stroke patients with hemiplegic gait.

OBJECTIVE: To evaluate the kinematic features of rear-foot motion during gait in hemiplegic stroke patients, using anterior ankle-foot orthoses (AFOs), posterior AFOs, and no orthotic assistance. DESIGN: Crossover design with randomization for the interventions. SETTING: A rehabilitation center for adults with neurologic disorders. PARTICIPANTS: Patients with hemiplegia due to stroke (n=14) and able-bodied subjects (n=11). INTERVENTIONS: Subjects with hemiplegia were measured walking under 3 conditions with randomized sequences: (1) with an anterior AFO, (2) with a posterior AFO, and (3) without an AFO. Control subjects were measured walking without an AFO to provide a normative reference. MAIN OUTCOME MEASURES: Rear-foot kinematic change in the sagittal, coronal, and transverse planes. RESULTS: In the sagittal plane, compared with walking with an anterior AFO or without an AFO, the posterior AFO significantly decreased plantar flexion to neutral at initial heel contact (P=.001) and the swing phase (P<.001), and increased dorsiflexion at the stance phase (P=.002). In the coronal plane, the anterior AFO significantly increased maximal eversion to neutral (less inversion) at the stance phase (P=.025), and decreased the maximal inversion angle at the swing phase when compared with using no AFO (P=.005). The posterior AFO also decreased the maximal inversion angle at the swing phase as compared with no AFO (P=.005). In the transverse plane, when compared with walking without an AFO, the anterior AFO and posterior AFO decreased the adduction angle significantly at initial heel contact (P=.004). CONCLUSIONS: For poststroke hemiplegic gait, the posterior AFO is better than the anterior AFO in enhancing rear-foot dorsiflexion during a whole gait cycle. The anterior AFO decreases rear-foot inversion in both the stance and swing phases, and the posterior AFO decreases the rear-foot inversion in the swing phase when compared with using no AFO.

Outcomes of patients with hypertrophic cardiomyopathy and acute myocardial infarction: a propensity score-matched, 15-year nationwide population-based study in Asia.

OBJECTIVES: Hypertrophic cardiomyopathy (HCM) entails thickening of the myocardium and an increased risk of ischaemia. However, the prognosis of patients with HCM with acute myocardial infarction (AMI) is incompletely understood. METHODS: Medical information was retrieved from the Taiwan National Health Insurance Research Database in 1997-2011. The exclusion criteria were patients <18 years old, and history of AMI, coronary intervention, aortic valve disease, disease of the pericardium, heart surgery, device implantation, venous thromboembolism, cardiac transplant, congenital heart disease and end-stage renal disease on dialysis. Patients with HCM with AMI were compared with propensity score (PS)-matched patients with AMI without HCM. The primary endpoints were in-hospital and 1-year cardiovascular events. RESULTS: In total, 201 166 patients were admitted for AMI. There were 177 058 patients with new-onset AMI, 257 with HCM and 176 801 without HCM after exclusion criteria. Using 1:4 PS matching, the study population consisted of patients with AMI, 257 with HCM and 1028 without HCM. Patients with AMI with HCM received significantly less coronary intervention (OR=0.46; 95% CI 0.32 to 0.65; p<0.001), coronary intervention with stenting (OR=0.33; 95% CI 0.20 to 0.57; p<0.001) and coronary artery bypass graft surgery (OR=0.22; 95% CI 0.05 to 0.90; p=0.036), and fewer episodes of shock (OR=0.64; 95% CI 0.48 to 0.86; p=0.003) and in-hospital death (OR=0.46; 95% CI 0.30 to 0.70; p<0.001), compared with patients with AMI without HCM. Specifically, for patients with HCM with AMI, AMI occurred predominantly (82.5%) in the form of ischaemia without requiring coronary stenting. Patients with AMI with HCM had significantly better survival than patients without HCM (HR=0.66; 95% CI 0.51 to 0.85; p=0.001) during the 1-year follow-up. CONCLUSIONS: This is the first PS-matched study to compare the prognosis of patients with AMI with and without HCM. Compared with patients with AMI without HCM, patients with HCM had significantly better in-hospital and within 1-year outcomes.

Comparison of clinical outcomes in peripartum cardiomyopathy and age-matched dilated cardiomyopathy: A 15-year nationwide population-based study in Asia.

Peripartum cardiomyopathy (PPCM), often classified as a form of dilated cardiomyopathy (DCM), is the myocardial dysfunction that occurs in late pregnancy and through the first few postpartum months.The aim of this study is to investigate the differences in the clinical outcomes of PPCM and DCM.Electronic medical records from 1997 to 2011 were retrieved from the Taiwan National Health Insurance Research Database. Patients with PPCM were compared with age- and clinical characteristics-matched patients with DCM. Primary outcomes were 1- and 3-year heart failure (HF) readmission, cardiac death, all-cause mortality, and major adverse cardiovascular events. Secondary outcomes were myocardial infarction, new onset of dialysis, heart transplant, and cerebrovascular accident. Follow-up period was divided into "within the first year" and "after the first year."A total of 527,979 patients (253,166 females) were hospitalized with a principal diagnosis of HF during 1997 to 2011 period. After excluding patients aged <18 and >50 years, patients with other forms of HF, and those with a history of cerebrovascular accidents or coronary artery disease, 797 patients with PPCM and 1267 patients with DCM were evaluated. Propensity score matching yielded 391 patients in each group. Patients with DCM had a significantly worse prognosis compared to those with PPCM for all primary and secondary outcomes at the 1- and 3-year follow-ups. After 1 year, the HF readmission rate did not significantly differ between the 2 diseases, suggesting that HF medications should be aggressively instituted in patients with PPCM.This is the first study to directly compare the clinical outcomes between age-matched patients with PPCM and DCM. Patients with PPCM had a significantly better prognosis across all cardiovascular endpoints compared to patients with DCM.

Clinical outcomes of peripartum cardiomyopathy: a 15-year nationwide population-based study in Asia.

Peripartum cardiomyopathy (PPCM) is the development of heart failure during late pregnancy to months postpartum with potential fatal outcome. However, the disease is not well-studied in Asia.We aimed to investigate the epidemiology and clinical outcomes of PPCM in Taiwan.Electronic medical records were retrieved from Taiwan National Health Insurance Research Database from 1997 to 2011. Patients with PPCM were separated into 3 groups based on the timing of diagnosis. Early: PPCM diagnosed first to ninth month of pregnancy. Traditional: PPCM diagnosed last month of pregnancy till fifth month post-delivery. Late: PPCM diagnosed sixth to twelfth month post-delivery. Primary outcomes defined as cardiac death, all-cause mortality, and major adverse cardiovascular events (MACE) within 1 year.A total of 3,506,081 deliveries during 1997 to 2011 were retrieved and 925 patients with PPCM were identified. Overall incidence of PPCM was 1:3,790 during the 15 years. Early, Traditional, and Late group each had 88, 742, and 95 patients. Cardiac death occurred in 31 patients, all-cause mortality in 72 patients, and MACE in 65 patients. Late group had 2- to 3-fold event rates in cardiac death, all-cause mortality, and MACE compared with Early and Traditional groups. Cumulative incidence showed significant differences for cardiac death (P = .0011), all-cause mortality (P = .0031), and MACE (P = .0014) among 3 groups. Multivariate Cox model showed Late group had significantly worse outcomes after adjusted for clinical variables compared with 2 other groups.Our study is the largest national cohort among Asian countries that showed timing of diagnosis of PPCM had different outcomes. Late diagnosis portended significantly increased morbidity and mortality, even after adjusted for clinical variables.

Botulinum Toxin type A injections for patients with painful hallux valgus: a double-blind, randomized controlled study.

Hallux valgus (HV) related pain and disability remains a medical challenge to date. We have evaluated the therapeutic effect of intramuscular Botulinum Toxin type A (BTX-A) injection on painful HV in a double-blind randomized controlled trial. Sixteen patients having painful HV in at least one foot from the Department of Physical Medicine and Rehabilitation at a medical center in northern Taiwan have participated. Patients were randomized into two groups to receive intramuscular injections of either BTX-A or normal saline (NS) to the oblique and transverse heads of the adductor hallucis, flexor hallucis brevis and extensor hallucis longus muscles. Primary outcome measurements were selected from the Taiwan Chinese version of the Foot Function Index subscales on pain (questions 1-6, 9) and disability (question 10-18). The secondary outcome measurement was the HV angle. Patients were assessed at baseline and at 1, 2, 3, and 6 months after treatment. The demographic data and measurements were comparable between the two groups at baseline (p>0.05). BTX-A and NS reduced pain and disability one month after injection. Pain reduction induced by BTX-A injection lasted for at least 6 months while that induced by NS lasted for only 1 month. In addition, patients in the BTX-A group showed greater improvement in pain score (p<0.001), disability score (p<0.05), and HV angle (p<0.05) than patients in the NS group. The results reflected that HV-related muscle injection of BTX-A resulted in a marked reduction in pain for up to 6 months.

Botulinum toxin type A on oral health in treating sialorrhea in children with cerebral palsy: a randomized, double-blind, placebo-controlled study.

Intrasalivary gland injection of botulinum toxin type A is known to treat sialorrhea effectively in children with cerebral palsy. However, oral health may be compromised with escalating dose. In this randomized, double-blind, and placebo-controlled pilot trial, the authors aim to determine the therapeutic effect of low-dose, ultrasonography-controlled botulinum toxin type A injection to bilateral parotid and submandibular glands on oral health in the management of sialorrhea. Twenty children diagnosed with cerebral palsy were randomly assigned to 2 groups. The treatment group received botulinum toxin type A injections, whereas the control received normal saline in the same locations. The authors evaluated subjective drooling scales, salivary flow rate, and oral health (salivary compositions and cariogenic bacterial counts). A significant decrease was found in salivary flow rate at the 1- and 3-month follow-up in the botulinum toxin-treated group. The authors suggest that current protocol can effectively manage sialorrhea while maintaining oral health.