Optimizing shoulder elevation assist rate in exoskeletal rehabilitation based on muscular activity indices: a clinical feasibility study.

BACKGROUND: Restoring shoulder function is critical for upper-extremity rehabilitation following a stroke. The complex musculoskeletal anatomy of the shoulder presents a challenge for safely assisting elevation movements through robotic interventions. The level of shoulder elevation assistance in rehabilitation is often based on clinical judgment. There is no standardized method for deriving an optimal level of assistance, underscoring the importance of addressing abnormal movements during shoulder elevation, such as abnormal synergies and compensatory actions. This study aimed to investigate the effectiveness and safety of a newly developed shoulder elevation exoskeleton robot by applying a novel optimization technique derived from the muscle synergy index. METHODS: Twelve chronic stroke participants underwent an intervention consisting of 100 robot-assisted shoulder elevation exercises (10 × 10 times, approximately 40 min) for 10 days (4-5 times/week). The optimal robot assist rate was derived by detecting the change points using the co-contraction index, calculated from electromyogram (EMG) data obtained from the anterior deltoid and biceps brachii muscles during shoulder elevation at the initial evaluation. The primary outcomes were the Fugl-Meyer assessment-upper extremity (FMA-UE) shoulder/elbow/forearm score, kinematic outcomes (maximum angle of voluntary shoulder flexion and elbow flexion ratio during shoulder elevation), and shoulder pain outcomes (pain-free passive shoulder flexion range of motion [ROM] and visual analogue scale for pain severity during shoulder flexion). The effectiveness and safety of robotic therapy were examined using the Wilcoxon signed-rank sum test. RESULTS: All 12 patients completed the procedure without any adverse events. Two participants were excluded from the analysis because the EMG of the biceps brachii was not obtained. Ten participants (five men and five women; mean age: 57.0 [5.5] years; mean FMA-UE total score: 18.7 [10.5] points) showed significant improvement in the FMA-UE shoulder/elbow/forearm score, kinematic outcomes, and pain-free passive shoulder flexion ROM (P < 0.05). The shoulder pain outcomes remained unchanged or improved in all patients. CONCLUSIONS: The study presents a method for deriving the optimal robotic assist rate. Rehabilitation using a shoulder robot based on this derived optimal assist rate showed the possibility of safely improving the upper-extremity function in patients with severe stroke in the chronic phase.

Decision Tree Analysis Accurately Predicts Discharge Destination After Spinal Cord Injury Rehabilitation.

OBJECTIVES: To predict discharge destination after spinal cord injury (SCI) rehabilitation. STUDY DESIGN: A retrospective, single-center study. We collected the following data from medical charts: age, sex, living arrangement before injury, acute length of stay (LOS), level of injury on admission, American Spinal Injury Association Impairment Scale (AIS) on admission, Upper Extremity Motor Score (UEMS) on admission, Lower Extremity Motor Score on admission (LEMS), Spinal Cord Independence Measure (SCIM) scores on admission and discharge, and discharge destination. A decision tree algorithm was used to establish prediction models in a train-test split manner using features on admission or discharge. SETTING: A spinal center in Tokyo, Japan. PARTICIPANTS: Participants were individuals with SCI admitted to our hospital from March 2016 to October 2021 for the first rehabilitation after the injury. The study included 210 participants divided into 2 groups: training (n=140) and testing (n=70). Random sampling without replacement was used. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prediction accuracy was evaluated with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating curve (AUC). RESULTS: AIS was significantly different between the groups. The prediction model using total SCIM scores on discharge (D-Classification and Regression Tree [CART]) revealed that a cut-off value of 40 accurately predicted the discharge destination. In contrast, the prediction model using features on admission (A-CART) revealed that subtotal SCIM mobility scores of 5, age of 74 years, and UEMS of 23 were significant predictors. Sensitivity, specificity, PPV, NPV, and AUC of D-CART and A-CART were 0.837, 0.810, 0.911, 0.680, and 0.832 and 0.857, 0.810, 0.913, 0.708, and 0.869, respectively. CONCLUSIONS: D-CART and A-CART showed comparable prediction accuracies. This suggests that, even during the early stages of rehabilitation, it is possible to predict the discharge destination.

Functional Outcome Prediction After Spinal Cord Injury Using Ensemble Machine Learning.

OBJECTIVES: To establish a machine learning model to predict functional outcomes after SCI with Spinal Cord Independence Measure (SCIM) using features present at the time of rehabilitation admission. STUDY DESIGN: A retrospective, single-center study. The following data were collected from the medical charts: age, sex, acute length of stay (LOS), level of injury, American Spinal Injury Association Impairment Scale (AIS), motor scores of each key muscle, Upper Extremity Motor Score (UEMS), Lower Extremity Motor Score (LEMS), SCIM total scores, and subtotal scores on admission and discharge. Based on the multivariate linear regression analysis, age, acute LOS, UEMS, LEMS, and SCIM subtotal scores were selected as features for machine learning algorithms. Random forest, support vector machine, neural network, and gradient boosting were used as the base models and combined using ridge regression as a metamodel. SETTING: A spinal center in Tokyo, Japan. PARTICIPANTS: Participants were individuals with SCI admitted to our hospital from March 2016 to October 2021 for the first rehabilitation after the injury. They were divided into 2 groups: training (n=140) and testing (n=70). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The root-mean-square error (RMSE), R2, and Mean Absolute Error (MAE) were used as accuracy measures. RESULTS: RMSE, R2, and MAE of the meta-model using the testing group were 9.7453, 0.8835, and 7.4743, respectively, outperforming any other single base model. CONCLUSIONS: Our study revealed that functional prognostication could be achieved using machine-learning methods with features present at the time of rehabilitation admission. Goals can be set at the beginning of rehabilitation. Moreover, our model can be used to evaluate advanced medical treatments, such as regenerative medicine.

Retrospective study on the trajectories of lower limb volume after outpatient-based complex decongestive therapy in post-operative gynecological cancer patients with lymphedema.

PURPOSE: To determine the effect of outpatient-based complex decongestive therapy in patients with secondary lower limb lymphedema (LLL) after gynecologic cancer surgery using group-based trajectory modeling (GBTM), and to examine factors predictive of the treatment course. METHODS: This retrospective study included participants who underwent surgery for gynecological cancer with pelvic lymph node dissection and subsequently visited the outpatient clinic for the treatment of stage II LLL according to the International Society of Lymphology. The improvement rate of edema at the initial visit and 3, 6, and 12 months later was assessed by calculating the volume of the lower extremity using the circumferential method. For evaluation of the patterns of treatment course, logistic regression analysis was performed after group estimation by the trend of the treatment course using GBTM. RESULTS: A total of 148 women (mean age 60.6 years (standard deviation: 13.4 years)) were analyzed. Three improvement trajectories were identified: (1) no response group, with worsening rather than improvement (n = 26); (2) moderate response group, with a slow improvement rate (n = 89); and (3) high response group, with a high improvement rate (n = 33). In addition, adherence to compression therapy at 3 months post-intervention was found to be a predictor in the no response group. CONCLUSIONS: GBTM estimated that there are three patterns of the treatment course in patients with LLL after gynecologic cancer surgery. Adherence to compression therapy at 3 months post-intervention is a predictor of the treatment effectiveness.

Priority of the basic and instrumental activities of daily living in older patients with cancer prescribed rehabilitation: a cross-sectional survey.

BACKGROUND: There is no information on whether vulnerable older patients with cancer consider basic activities of daily living (BADL) and instrumental activities of daily living (IADL) important outcomes. Our survey aimed to investigate the priority of BADL and IADL in outcomes among vulnerable older patients with cancer. METHODS: This was a single-center survey in a Japanese cancer center. Eligible patients were ≥ 65 years of age and were prescribed in-hospital rehabilitation while under cancer treatment. Using original self-administered ranking questionnaires, patients were asked to rank outcomes and subdomain of BADL and IADL. High-priority domains were defined as the highest, second-highest, and third-highest priority domains in individuals. RESULTS: A total of 169 patients were analyzed. The mean age was 74.0 years (standard deviation, 5.1 years) and the number of males was 107 (63%). The order of ranking of high-priority outcomes was BADL and IADL (n = 155), cognitive function (n = 91), mental function (n = 82), nutrition (n = 61), social function (n = 51), comorbidity (n = 39), and life span (n = 28). The top three high-priority independence subdomains of BADL and IADL were toilet use (n = 140), feeding (n = 134), and mobility (n = 69) among the BADL and shopping (n = 93), food preparation (n = 88), and ability to handle finances (n = 85) among the IADL. CONCLUSIONS: BADL and IADL can be considered the most important health outcomes in clinical trials and in practice among older patients with cancer and physical vulnerabilities.

Effect of Postoperative Oral Intake Status on Sarcopenia Six Months After Esophageal Cancer Surgery.

PURPOSE: In patients with esophageal cancer, skeletal muscle mass has been reported to decrease progressively after surgery and be independently associated with a poor prognosis. The purpose of this study was to investigate perioperative changes in dysphagia, oral intake status, and nutritional status and identify factors related to sarcopenia 6 months after esophagectomy. METHODS: A total of 134 patients who underwent radical resection for thoracic esophageal cancer between March 2016 and July 2019 were analyzed retrospectively. The diagnosis of sarcopenia was made by CT taken 6 months postoperatively using the cut-off criteria of skeletal muscle index (SMI) < 52.4 cm2/m2 for male and SMI < 38.5 cm2/m2 for female patients. As factors related to postoperative sarcopenia, dysphagia, oral intake status, nutritional status, and physical function were extracted from the medical records. Multivariate logistic regression analysis was performed to identify perioperative risk factors related to sarcopenia 6 months after surgery. RESULTS: Of the 134 patients, 34.3% were judged to be unable to start oral intake on swallowing assessment. At discharge, 30.6% received tube feeding with or without oral intake. In the non-oral intake group on swallowing assessment, a significantly higher proportion of patients received tube feeding at discharge (p = 0.014). Preoperative BMI, postoperative handgrip strength, and tube feeding at discharge were independent risk factors for sarcopenia 6 months after esophagectomy in male patients. CONCLUSION: Tube feeding at discharge is significantly related to postoperative sarcopenia in patients with esophageal cancer. Identifying high-risk groups might allow early detection of malnutrition and provision of appropriate care.

Impacts of increases and decreases of drugs on rehabilitation outcomes of subacute stroke patients.

OBJECTIVE: To examine changes in drugs for subacute stroke patients and elucidate the impact of medications on rehabilitation outcomes. MATERIALS AND METHODS: A total of 295 subacute stroke patients who were admitted to the convalescent rehabilitation ward between June 2018 and May 2019 were included. Polypharmacy was defined as five or more drugs at admission. The primary outcome was the Functional Independence Measure Total score (FIM-T) at discharge. Multiple regression analysis was performed to examine the relationships between the FIM-T at discharge and drug changes or other factors. This study was conducted in two stages. The first analysis included all stroke patients, and the second analysis included only stroke patients with polypharmacy. RESULTS: On multiple regression analysis, the number of drugs at admission (ß=-0.628) was associated with FIM-T at discharge of all stroke patients. Furthermore, the number of additional drugs during hospitalization (ß=-1.964) was associated with FIM-T at discharge in the 176 stroke patients with polypharmacy. CONCLUSION: This study suggested that the number of drugs at admission and the addition of drugs during hospitalization might have a negative impact on the rehabilitation outcomes of subacute stroke patients.

Prognostic Impact of Postoperative Loss of Skeletal Muscle Mass in Patients Aged 70 Years or Older with Esophageal Cancer.

BACKGROUND: The number of patients with esophageal cancer aged ≥ 70 years with a poor prognosis is increasing. In general patients with esophageal cancer, postoperative loss of skeletal muscle mass (SMM) is a prognostic factor. This study was designed to investigate the prognostic impact of postoperative loss of SMM in patients aged ≥ 70 years with esophageal cancer. METHODS: This study was a single-center, retrospective cohort study. Patients with esophageal cancer who underwent R0 esophagectomy between 2016 and 2020 were included. The percentage postoperative loss of skeletal muscle mass index (SMI%) was calculated using computed tomography images before and at 4 ± 2 months after surgery. RESULTS: The number of subjects in the ≥ 70-year and < 70-year age groups was 166 and 218, respectively. The median SMI% was 5% in all patients; thus, 5% was defined as the cutoff point to define major loss of SMI. Major loss of SMI impacted 3-year overall survival (OS) in the ≥ 70-year age group, independent of age, sex, clinical stage, pathological T and N factors, Charlson comorbidity index, and length of hospital stay (adjusted hazard ratio [HR]: 4.400; 95% confidence interval: 1.202-16.105; P = 0.025). The adjusted HR of major loss of SMI in the ≥ 70-year age group was higher than in the < 70-year age group (adjusted HR: 4.400 vs. 2.388, respectively). CONCLUSIONS: Postoperative loss of SMI in patients with esophageal cancer aged ≥ 70 years more strongly impacted 3-year OS than in patients aged < 70 years.

Prognostic Impact of the Loss of Skeletal Muscle Mass During Neoadjuvant Chemotherapy on Older Patients with Esophageal Cancer.

BACKGROUND: In older adults, skeletal muscle mass is an important factor for health and prognosis. The loss of SMM during neoadjuvant therapy affects the prognosis of patients with locally advanced esophageal cancer. However, information is limited regarding this possibility in older patients. This study aimed to establish the prognostic impact of SMM loss during neoadjuvant chemotherapy on older patients with locally advanced esophageal cancer. METHODS: This was a single-center retrospective cohort study. Patients age 65 years or older had undergone R0 curative esophagectomy after NAC. The skeletal muscle mass index before and after NAC was calculated from computed tomography images. The percentage change in the SMI during NAC (SMI%) was calculated from the SMI before and after NAC. RESULTS: The study analyzed 150 patients with a mean age of 71.1 ± 3.7 years. The mean value of the SMI was 42.7 ± 7.2 cm2/m2 before NAC, and the SMI% was - 6.4% ± 5.9%. The cutoff of SMI% for overall survival was defined by the log-rank test as - 12%. The Cox proportional hazard model showed that major loss of the SMI (≥ 12%) significantly influenced OS (hazard ratio, 2.490; 95% confidence interval, 1.121-5.529; p = 0.025) independently of age, sex, pathologic T and N factors, or treatment regimen. CONCLUSIONS: Major SMI loss has an impact on OS after R0 curative esophagectomy for older patients with locally advanced esophageal cancer.

Cognitive function is associated with home discharge in subacute stroke patients: a retrospective cohort study.

AIM: To investigate the cognitive function and its relation to the home discharge of patients following subacute stroke. METHODS: This retrospective cohort study included 1,229 convalescent patients experiencing their first subacute stroke. We determined discharge destination and demographic and clinical information. We recorded the following measurement scores: Mini-Mental State Examination (MMSE) score, Stroke Impairment Assessment Set score, grip strength, and Functional Independence Measure (FIM). We performed a multivariable logistic regression analysis with the forced-entry method to identify factors related to home discharge. RESULTS: Of the 1,229 participants (mean age: 68.7 ± 13.5 years), 501 (40.8%), 735 (59.8%), and 1,011 (82.3%) were female, had cerebral infarction, and were home discharged, respectively. Multivariable logistic regression analysis revealed that age (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.91 - 0.96; P < 0.001), duration from stroke onset to admission (OR, 0.98; 95% CI, 0.96 - 0.99; P = 0.003), living situation (OR, 4.40; 95% CI, 2.69 - 7.20; P < 0.001), MMSE score at admission (OR, 1.05; 95% CI, 1.00 - 1.09; P = 0.035), FIM motor score at admission (OR, 1.04; 95% CI, 1.01 - 1.06; P = 0.001), and FIM cognitive score at admission (OR, 1.08; 95% CI, 1.04 - 1.13; P < 0.001) were significantly associated with home discharge. CONCLUSIONS: MMSE at admission is significantly associated with home discharge in patients with subacute stroke.

Rehabilitation for elderly patients with cancer.

If physical functions are impaired in patients with cancer owing to the progression of the disease and the treatment processes, their activities of daily living (ADLs) decline; thus, the quality of life is impacted. Elderly patients with cancer constitute a group with diverse basic physical, mental and social skill levels owing to aging. Given that there are potential risks of frailty and sarcopenia, their physical functions and ADL are prone to decline. Furthermore, there are many cases in which patients live alone, isolated from the society or face social problems. Therefore, in the treatment of elderly patients with cancer, geriatric assessment is used to comprehensively assess comorbidity, physical functions and psychophysiological/social/environmental situations and a system that provides supportive care is required. As part of this process, cancer rehabilitation plays an important role in prevention of complications, functional recovery and maintenance and improvement of physical functions and ADL until the time of palliative care. To provide rehabilitation, utmost attention must be paid to issues unique to elderly people, such as frailty, sarcopenia, dementia, delirium, pain management, depression and undernutrition/dysphagia.

Rehabilitation in Acute COVID-19 Patients: A Japanese Retrospective, Observational, Multi-Institutional Survey.

OBJECTIVE: To investigate the changes in activities of daily living (ADLs) and the conditions of rehabilitation for acute COVID-19 patients in Japan. DESIGN: Retrospective, observational survey. SETTING: Four tertiary hospitals with intensive care units and one secondary hospital in Japan. PARTICIPANTS: COVID-19 patients (N=478) admitted to 5 hospitals INTERVENTIONS: : Not applicable. MAIN OUTCOME MEASURES: Walking ability and swallowing status were assessed using the FIM locomotion item and Food Intake Scale at admission and discharge. The physiatrists of each hospital were also surveyed regarding the factors that influenced decisions to provide rehabilitation. RESULTS: Excluding patients who died, the proportion of critical patients who could walk independently at discharge was 63%, and the proportion of those who were able to take 3 meals orally at discharge was 90%. Rehabilitation was provided to 13.4% of all patients and to 58.3% of patients with critical symptoms. CONCLUSIONS: After COVID-19 treatment, patients, especially those with critical symptoms, still have functional disabilities related to walking and swallowing. It is possible that sufficient rehabilitation could not be provided during the period studied.

Preoperative maximum phonation time as a predictor of pneumonia in patients undergoing esophagectomy.

PURPOSE: Esophagectomy is a highly invasive procedure, associated with several postoperative complications including pneumonia, anastomotic leakage, and sepsis, which may result in multiorgan failure. Pneumonia is considered a major predictor of poor long-term prognosis, so its prevention is important for patients undergoing surgery for esophageal cancer. METHODS: The subjects of this study were 137 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January, 2012 and December, 2016. Patients who underwent R0 or R1 resection or esophagectomy with organ excision were included. Patients who underwent salvage surgery or resection of recurrent laryngeal nerve, and those with preoperative recurrent laryngeal nerve palsy, were excluded. We investigated the effect of the maximum phonation time on the development of postoperative pneumonia. RESULTS: Pneumonia developed more frequently in patients with a long operative time, clinically left recurrent nerve lymph node metastasis, and a short preoperative maximum phonation time (p = 0.074, 0.046, and 0.080, respectively). Pneumonia was also more common in men with an abnormal maximum phonation time (p = 0.010). CONCLUSIONS: The maximum phonation time is a significant predictor of postoperative pneumonia after esophagectomy in men.

Effects of Galvanic Vestibular Stimulation on Subjective Visual Vertical and Sitting Balance in Patients with Stroke.

OBJECTIVE: This study aimed to examine the effects of galvanic vestibular stimulation (GVS) on visual vertical cognition and sitting balance in stroke patients. MATERIALS AND METHODS: Patients with unilateral supratentorial infarction and hemorrhagic lesions and healthy controls were recruited. Bipolar GVS was performed through the bilateral mastoid processes with an 1.5-mA electric current. Each participant received three stimulation patterns: right anode-left cathode, left anode-right cathode, and sham. The subjective visual vertical (SVV) and center of gravity positions in the sitting posture were measured in three groups of participants: patients with right hemisphere lesions, patients with left hemisphere lesions, and in healthy controls. Changes in the SVV and center of gravity positions before and during galvanic vestibular stimulation were assessed. RESULTS: In each group, eight individuals were recruited for SVV measurements and nine individuals for center of gravity measurements. We found changes due to polarity of stimulation on the SVV and mediolateral changes in the center of gravity in the sitting position of patients with stroke, while there was no significant difference between groups or interaction of the two factors (polarity vs. group). CONCLUSION: Changes in the visual vertical cognition and sitting balance occur during GVS in patients with stroke. GVS is a potential tool for ameliorating balance dysfunction in patients with stroke.

Unmet need for palliative rehabilitation in inpatient hospices/palliative care units: a nationwide post-bereavement survey.

In end-of-life care, rehabilitation for terminally ill cancer patients is inconsistently provided and rarely discussed. We sought to clarify the prevalence of unmet rehabilitation need for patients admitted to inpatient hospice/palliative care units as perceived by bereaved family members. We conducted a nationwide questionnaire survey of 1001 family members of cancer patients who died at inpatient hospices/palliative care units. For cancer patients who did not receive rehabilitation, we asked if family members perceived that the patient would have wanted rehabilitation intervention. Data were obtained from 416 respondents. Of these, 281 (67.5%) cases received no rehabilitation. The need for physical modalities was the most frequently reported (27.8%; 95% CI: 22.6-33.4), followed by relief of dyspnea (25.6%; 95% CI: 20.6-31.1) and treatment of edema (23.8%; 95% CI: 19.0-29.3). A non-negligible proportion of bereaved families reported unmet need for rehabilitation related to symptom management in inpatient hospices/palliative care units.

The current status of inpatient cancer rehabilitation provided by designated cancer hospitals in Japan.

OBJECTIVE: This survey was conducted to clarify the current status of inpatient cancer rehabilitation provided by designated cancer hospitals in Japan. METHODS: A survey questionnaire was sent to 427 designated cancer hospitals in Japan. Information was sought regarding whether inpatient cancer rehabilitation was provided by the center, and if so, whether respondents regarded such provision as satisfactory. RESULTS: Responses were obtained from 235/427 surveyed institutions (55.0%). Cancer rehabilitation was provided in inpatient settings by 97.4%. Two-thirds of respondents (67.7%) regarded inpatient cancer rehabilitation provision as still inadequate. The primary reasons claimed for this inadequacy were a lack of human resources, a lack of rehabilitation professionals with the requisite knowledge/skills and patients who would benefit from cancer rehabilitation present but not prescribed. The total number of rehabilitation staff was identified as associated factor of inadequate inpatient cancer rehabilitation in multivariate analysis (odds ratio = 0.979, 95% confidence interval = 0.96-1.00, P = 0.009). CONCLUSIONS: In order to provide adequate cancer rehabilitation, a sufficient supply of rehabilitation staff, education and recognition of the need for cancer rehabilitation within oncology units are necessary.

Postural differences in the immediate effects of active exercise with compression therapy on lower limb lymphedema.

PURPOSE: Although regarded as an important treatment for lymphedema, the therapeutic effects of active exercise with compression therapy (AECT) are supported by little evidence. The purpose of this study was to determine the relative benefits of AECT with different postures for patients with lower limb lymphedema (LLL). METHODS: Eighteen women with LLL secondary to surgical treatment of gynecological cancer, completed (1) AECT in a seated position (seated AECT), (2) AECT in a supine position (supine AECT), and (3) compression-only therapy in a supine position (CT) in this randomized, controlled, crossover trial. AECT was performed on a bicycle ergometer while wearing elastic compression bandages. Each intervention was performed for 15 min, and the three conditions were separated by a 1-week washout period. Lower-limb volumes were evaluated using a PerometerTM sensor (Pero-system, Wuppertal, Germany), and symptom severity was assessed before and after each intervention using a visual analog scale (pain, heaviness) and palpation (pitting, stiffness). The effects of the interventions were estimated using linear mixed-effect models. RESULTS: The magnitude of limb volume decreases differed significantly among the interventions, with a greater decrease after supine AECT than after CT. Pre-intervention pitting severity and skin stiffness were significantly correlated with the magnitude of volume decrease after all interventions and after AECT in the supine position, respectively. CONCLUSIONS: Supine AECT using a bicycle ergometer has marked immediate effects to decrease the fluid volume of severe LLL. CLINICAL TRIAL REGISTRATION: UMIN clinical trial registry (UMIN-CTR; ID000020129) by CONSORT 2010, TRN R000023253, December 9, 2015.

Risk factors of impairment of shoulder function after axillary dissection for breast cancer.

OBJECTIVES: Postoperative shoulder joint dysfunction has been observed at a certain rate after breast cancer surgery with axillary lymph node dissection. The purposes of this study were to verify the feasibility and effects of home-based exercise using a DVD and clarify the target of intensive intervention with physiotherapy by identifying the factors that cause postoperative shoulder dysfunction. METHODS: The study comprised 237 female patients who underwent breast cancer surgery with axillary lymph node dissection, whose data were acquired until 3 months postoperatively. All patients were instructed to exercise at home using a DVD. Range of motion (ROM) of shoulder flexion and abduction and the disability of the arm, shoulder, and hand (DASH) score were measured before surgery, 1 week and 1, 2, and 3 months after surgery. As factors influencing the recovery of shoulder ROM at 3 months after surgery, the presence or absence of radiation and factors up to 1 month after surgery (age, body mass index, the relationship between operated side and dominant side of the hand, treatment modalities, and complications). RESULTS: Shoulder ROM and DASH scores had gradually recovered from 1 week to 3 months postoperatively. As the results of the multivariate analysis, the factors that were associated with the recovery of ROM of shoulder flexion at 3 months were the side of surgery corresponding to the dominant hand (negative factor) and the presence of paresthesia at 1 week postoperatively (positive factor) (p < 0.05). Radiation therapy and the side of surgery corresponding to the dominant hand were negative factors for the recovery of shoulder abduction (p < 0.01). Regarding the feasibility of the home exercise, 214/229 (93.4%), 172/210 (81.9%), and 139/206 (67.5%) of patients performed exercise at least once a day at 1, 2, and 3 months after surgery, respectively. CONCLUSION: Our result indicated that the side of surgery corresponding to the dominant hand was the inhibiting factor for recovery for both shoulder flexion and abduction at 3 months after surgery. Home-based exercise with DVD was considered feasible. For the verification of this effectiveness, a randomized control study should be planned in the future.

Association of preoperative sarcopenia with postoperative dysphagia in patients with thoracic esophageal cancer.

BACKGROUND: The purpose of the current study was to clarify the relationship between clinical features of dysphagia after esophagectomy and preoperative sarcopenia. METHODS: A total of 187 cases were included in the current study. The psoas cross-sectional area on pre-treatment computed tomography was measured in thoracic esophageal cancer patients who underwent curative resection. The psoas muscle index (PMI) cut-off levels for sarcopenia were 6.36 cm2/m2 for men and 3.92 cm2/m2 for women. Swallowing function was evaluated using videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) at postoperative days 7-15, and classified according to the food intake level scale (FILS). Perioperative swallowing rehabilitation was performed in all cases. RESULTS: In the 187 included patients, the median PMI was 5.42 cm2/m2 for men and 3.43 cm2/m2 for women, and 133 cases (71%) met the sarcopenia criteria. The FILS <4 (no oral intake) was 15% in the non-sarcopenia group, and 38% in the sarcopenia group (P = 0.003). There was no significant difference in the incidence of postoperative complications, including pneumonia and re-admission due to pneumonia, between the two groups. Preoperative sarcopenia and recurrent laryngeal nerve palsy were be independent risk factors for postoperative dysphagia. CONCLUSIONS: Sarcopenic patients with esophageal cancer develop postoperative dysphagia more often than non-sarcopenic patients. Prehabilitation and nutritional support for patients with preoperative sarcopenia could play an important role to mitigate postoperative dysphagia.

Factors related to instrumental activities of daily living in persons with chronic thromboembolic pulmonary hypertension.

Instrumental activities of daily living (IADL) are significantly related to quality of life and mortality among individuals with heart disease. However, few reports have examined IADL in persons with chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to clarify factors related to IADL in persons with CTEPH. This retrospective, observational study enrolled 163 persons with CTEPH (mean ± standard deviation age = 65 ± 13 years; 68% female) admitted to the Department of Cardiology at Keio University Hospital between January 2015 and July 2019. The Frenchay Activities Index (FAI) was used to assess IADL. Age, sex, body mass index, World Health Organization functional class (WHO-FC), cardiac function (mean pulmonary arterial pressure, mean right atrial pressure, pulmonary capillary wedge pressure, and cardiac index), pulmonary function (percentage vital capacity, percentage forced expiratory volume in 1 s, diffusion capacity of carbon monoxide (DLCO)/alveolar volume (VA)), physical function (knee extension strength and walking speed), and 6-min walking distance (6MWD) were assessed. Multiple regression analysis was performed to identify factors significantly associated with FAI. Mean FAI was 25 ± 8. Univariate analysis showed that sex, WHO-FC, DLCO/VA, walking speed, and 6MWD were correlated with FAI. Multiple regression analysis showed that 6MWD (sß = 0.338, 95% CI 0.014-0.034, p < .001), sex (sß = 0.268, 95% CI 2.238-7.165, p < .001), and DLCO/VA (sß = 0.257, 95% CI 1.011-3.528, p < .001) were significantly correlated with FAI (R2 = 0.261). IADL were associated with exercise tolerance, sex, and DLCO/VA in persons with CTEPH. In the future, more details of IADL are expected to be clarified by analyzing individual components of IADL and investigating social background characteristics, including living environment.