Using aerobic exercise to improve health outcomes and quality of life in stroke: evidence-based exercise prescription recommendations.

BACKGROUND: Stroke patients often suffer from poor cardiovascular health and deficits in physical, psychosocial and cognitive functioning. Aerobic exercise training may be a viable treatment approach to address these health issues. The objective of this systematic review was to determine the effects of aerobic exercise on various indicators of health, functioning and quality of life in stroke patients. It was hypothesized that the systematic review would reveal compelling support for the effectiveness of aerobic exercise in stroke patients, such that detailed evidence-based exercise prescription recommendations could be derived. METHODS: Major electronic databases were searched systematically to identify randomized controlled studies that examined the effects of aerobic exercise in stroke patients (last search performed in January 2012). The methodological quality of each study was evaluated using the PEDro scale (9-10 = excellent; 6-8 = good; 4-5 = fair; <4 = poor). Based on the methodological quality and sample size used, the level of evidence was determined for each study (level 1: PEDro ≥6 and sample size >50; level 2: PEDro ≤5 or sample size ≤50). Meta-analysis was performed on a given outcome when appropriate. RESULTS: Twenty-five trials fulfilled the selection criteria, of which 8 were level 1 studies. Treadmill and cycle ergometer were the two most popular modalities used to provide aerobic training. The most commonly adopted exercise session duration and frequency was 21-40 min and 3-5 days per week, respectively. The duration of the training programme varied, ranging from 3 weeks to 6 months. Over 60% of the trials used a high training intensity [60-80% heart rate reserve (HRR)]. Meta-analysis showed a significant effect on peak oxygen consumption (p < 0.001), peak workload (p < 0.001), maximal gait speed (p = 0.003) and walking endurance (p < 0.001) in favour of aerobic exercise. Meta-analysis revealed no significant effect on self-selected gait speed, Berg balance score and Functional Independence Measure score. The efficacy of aerobic exercise in improving other health outcomes in physical, psychosocial and cognitive domains as well as quality of life was inconclusive. The health risk associated with engaging in such exercise is small. CONCLUSIONS: There is strong evidence that aerobic exercise (40-50% HRR progressing to 60-80%) conducted 20-40 min and 3-5 days per week is beneficial for enhancing aerobic fitness, walking speed and walking endurance in people who have had mild to moderate stroke and are deemed to have low cardiovascular risk with exercise after proper screening assessments (grade A recommendation). The effects of aerobic exercise on other health outcomes require further study.

The Placental NLRP3 Inflammasome and Its Downstream Targets, Caspase-1 and Interleukin-6, Are Increased in Human Fetal Growth Restriction: Implications for Aberrant Inflammation-Induced Trophoblast Dysfunction.

Fetal growth restriction (FGR) is commonly associated with placental insufficiency and inflammation. Nonetheless, the role played by inflammasomes in the pathogenesis of FGR is poorly understood. We hypothesised that placental inflammasomes are differentially expressed and contribute to the aberrant trophoblast function. Inflammasome gene expression profiles were characterised by real-time PCR on human placental tissues collected from third trimester FGR and gestation-matched control pregnancies (n = 25/group). The functional significance of a candidate inflammasome was then investigated using lipopolysaccharide (LPS)-induced models of inflammation in human trophoblast organoids, BeWo cells in vitro, and a murine model of FGR in vivo. Placental mRNA expression of NLRP3, caspases 1, 3, and 8, and interleukin 6 increased (>2-fold), while that of the anti-inflammatory cytokine, IL-10, decreased (<2-fold) in FGR compared with control pregnancies. LPS treatment increased NLRP3 and caspase-1 expression (>2-fold) in trophoblast organoids and BeWo cell cultures in vitro, and in the spongiotrophoblast and labyrinth in the murine model of FGR. However, the LPS-induced rise in NLRP3 was attenuated by its siRNA-induced down-regulation in BeWo cell cultures, which correlated with reduced activity of the apoptotic markers, caspase-3 and 8, compared to the control siRNA-treated cells. Our findings support the role of the NLRP3 inflammasome in the inflammation-induced aberrant trophoblast function, which may contribute to FGR.

The effects of whole body vibration therapy on bone mineral density and leg muscle strength in older adults: a systematic review and meta-analysis.

OBJECTIVE: A systematic review and meta-analysis of randomized controlled trials was undertaken to determine whether whole body vibration improves bone mineral density and leg muscle strength in older adults. DATA SOURCES: Sources included MEDLINE, CINAHL, EMBASE, PEDro, PubMed, Science Citation Index and the reference list of each eligible article. REVIEW METHODS: Article search and selection was performed independently by two researchers. The methodological quality of each selected article was rated by the PEDro scale. RESULTS: Thirteen randomized trials (18 articles) totalling 896 subjects fulfilled the selection criteria. Four were considered to have good or excellent methodological quality and the rest were rated as fair. Meta-analyses revealed that whole body vibration has no significant effect on hip or lumbar spine bone mineral density in older women when compared with no intervention or active exercise (P > 0.05). Whole body vibration, however, had a significant treatment effect on knee extension dynamic strength (standardized mean difference = 0.63, P = 0.006), leg extension isometric strength (standardized mean difference = 0.57, P = 0.003), and functional measures of leg muscle strength such as jumping height (standardized mean difference = 0.51, P = 0.010) and performance in sit-to-stand (standardized mean difference = 0.72, P < 0.001) among older adults compared with no intervention. CONCLUSION: Whole body vibration is beneficial for enhancing leg muscle strength among older adults. However, the review suggests that whole body vibration has no overall treatment effect on bone mineral density in older women. No randomized trial has examined the effects of whole body vibration on bone mineral density in older men.

Percutaneous intrarenal transplantation of differentiated induced pluripotent stem cells into newborn mice.

The in vivo engraftment of induced pluripotent stem cell (iPSC)-derived podocytes following allogeneic transplantation into host kidneys remains a challenge. Here we investigate the survival and engraftment of human dermal fibroblasts-derived differentiated iPSCs using a newborn mouse model, which represents a receptive immunoprivileged host environment. iPSCs were generated from skin biopsies of patients using Sendai virus reprogramming. Differentiation of nephrin (NPHS1)-green fluorescent protein (GFP) iPSCs into kidney podocytes (iPSC-PODs) was performed by the addition of Activin A, bone morphogenetic protein 7 (BMP7), and retinoic acid over 10 days of culture. To assess the in vivo incorporation of cells, undifferentiated iPSCs or day 10 iPSC-PODs, were labeled with either carboxyfluorescein succinimidyl ester (CFSE) or Qdot nanocrystals (Q705). Thereafter, 1 × 105 differentiated iPSC-PODs were injected directly into the kidneys of mouse pups at postnatal day one (P1). Using co-expression analysis of glomerular and podocyte-specific markers, Day 10 differentiated iPSC-PODs that were positive for podocin, were detected following direct kidney injection into newborn mice up to 1 week after transplantation. Undifferentiated iPSC-PODs were not detected at the same timepoint. The transplanted cells were viable and located in the outer nephrogenic zone where they were found to colocalize with, or sit adjacent to, cells positive for glomerular-specific markers including podocin, synaptopodin, and Wilms' tumor 1 (WT1). This study provides proof-of-principle that transplanted iPSC-POD can survive in recipient newborn mouse kidneys due to the immature and immunoprivileged nature of the developing postnatal kidneys.

Measuring environmental barriers faced by individuals living with stroke: development and validation of the Chinese version of the Craig Hospital Inventory of Environmental Factors.

OBJECTIVE: To develop and validate a Chinese version of the Craig Hospital Inventory of Environmental Factors. DESIGN: Descriptive case-series. SUBJECTS: A total of 107 individuals with chronic stroke and 56 age-matched healthy subjects. METHODS: The English version of the 25-item Craig Hospital Inventory of Environmental Factors was translated into Chinese using standardized procedures, and then administered to both the stroke and control groups. The same questionnaire was administered again to the stroke group 1-2 weeks after the first session. RESULTS: The Craig Hospital Inventory of Environmental Factors had good internal consistency (Cronbach's alpha = 0.916) and test-retest reliability (intra-class correlation coefficient = 0.845). It also had significant association with Personal Wellbeing Index (r(s) = -0.379, p = 0.001) but not with Fugl-Meyer Assessment upper limb (r(s) = -0.107, p = 0.320) and lower limb motor scores (r(s) = -0.032, p = 0.768) among stroke subjects, thus demonstrating convergent and discriminant validity, respectively. The mean Craig Hospital Inventory of Environmental Factors score in the stroke group was also significantly higher than that in controls (p = 0.020), thus showing good known-groups validity. CONCLUSION: The Chinese version of the Craig Hospital Inventory of Environmental Factors is a reliable and valid tool for evaluating the perceived environmental barriers experienced by people with chronic stroke.

Whole-body vibration has no effect on neuromotor function and falls in chronic stroke.

PURPOSE: Whole-body vibration therapy has gained increasing popularity in enhancing neuromotor function in various patient populations. It remains uncertain, however, whether whole-body vibration is beneficial when used in stroke patients. The aim of this randomized controlled trial was to examine the efficacy of whole-body vibration in optimizing neuromotor performance and reducing falls in chronic stroke patients. METHODS: Eighty-two chronic stroke patients were randomly assigned to either the experimental group or control group. The experimental group received 9-15 min of whole-body vibration (vertical vibration; frequency = 20-30 Hz. amplitude = 0.44-0.60 mm, peak acceleration = 9.5-15.8 m·s or 0.97-1.61 U of Earth gravitational acceleration (g) while performing a variety of dynamic leg exercises on the vibration platform. The control group performed the same exercises without vibration. The subjects underwent their respective training three times a week for 8 wk. Balance (Berg balance scale), mobility (10-m walk test and 6-min walk test), knee muscle strength (isokinetic dynamometry), and fall-related self-efficacy (activities-specific balance confidence scale) were assessed at baseline, immediately after the 8-wk training and at a 1-month follow-up. The incidence of falls was recorded until 6 months after the termination of training. RESULTS: Intention-to-treat analysis revealed similar significant improvement in all balance, mobility, muscle strength, and fall-related self-efficacy measures in both groups after the 8-wk treatment period (P < 0.001), and these were maintained at the 1-month follow-up. The incidence of falls did not differ significantly between the two groups (P > 0.05). CONCLUSIONS: The addition of the presently used whole-body vibration paradigm to a leg exercise protocol was no more effective in improving neuromotor performance and reducing the incidence of falls than leg exercises alone in chronic stroke patients who have mild to moderate motor impairments.

Changes in bone density and geometry of the upper extremities after stroke: a case report.

PURPOSE: The purpose of this study was to examine changes in bone density and geometry of the forearm region and motor function of the paretic upper extremity in a person with subacute stroke. Client Description: The participant was a 48-year-old man with right hemiparesis. INTERVENTION: Not applicable. Measures and Outcomes: The assessment of upper-extremity (UE) function and bone imaging took place at 3 months and 12 months after stroke. The participant had moderate motor impairment and severe disuse of the paretic UE 3 months after stroke. During the follow-up period, no substantial change in paretic UE function was observed. At the 12 month follow-up, the areal bone mineral density (aBMD) of the ultradistal and mid-regions of the paretic forearm, as measured by dual-energy X-ray absorptiometry, sustained a significant reduction of 7.9% and 5.9%, respectively. The non-paretic side, in contrast, had a significant 4.0% increase in aBMD of the mid-forearm and a 2.8% increase in aBMD of the total forearm. Significant findings from peripheral quantitative computed tomography were a reduction in total volumetric bone mineral density (-12.1%) and bone strength index (-20.6%) in the radius distal epiphysis on the paretic side and an increase in cortical bone mineral content (2.0%) and bone strength index (7.6%) in the radius diaphysis on the non-paretic side. IMPLICATIONS: After a stroke that resulted in moderate to severe UE impairment, a significant decline in bone mineral density was identified in various skeletal sites in the forearm region as the participant entered the subacute and chronic stages of recovery. The results point to the potential importance of early rehabilitative intervention in preventing unfavourable bone changes in the paretic upper limb among individuals with stroke.

The effect of whole body vibration on balance, mobility and falls in older adults: a systematic review and meta-analysis.

This systematic review aimed to examine the effect of WBV on balance, mobility and falls among older adults. The databases used included MEDLINE, the Excerpta Medica database, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library Databases of Systematic Reviews, Physiotherapy Evidence Database (PEDro), PubMed, and Science Citation Index (last search in October 2011). Randomized controlled trials that investigated the effect of WBV on balance, mobility or falls in older adults were included in this review. The PEDro score was used to examine the methodological quality of the selected studies. The effect of WBV on balance, mobility and fall-related outcomes were extracted. The data extraction and rating were performed by a researcher and the results were confirmed by the principal investigator. Meta-analysis was done if 3 or more studies measured the same outcome of interest. Among 920 articles screened, fifteen articles (thirteen trials) satisfied the criteria and were included in this review. Methodological quality was good for six of the studies (PEDro score=6-7). Meta-analysis revealed that WBV has a significant treatment effect in Tinetti Total Score (p<0.001), Tinetti Body Balance Score (p=0.010) and Timed-Up-and-Go test (p=0.004). No significant improvement was noted in Tinetti Gait Score after WBV training (p=0.120). The effect of WBV on other balance/mobility outcomes and fall rate remains inconclusive. To conclude, WBV may be effective in improving relatively basic balance ability and mobility among older adults, particularly frailer ones. More good-quality WBV trials are required.

Development and validation of the Chinese version of the Reintegration to Normal Living Index for use with stroke patients.

OBJECTIVE: To develop and validate a Chinese version of the Reintegration to Normal Living Index. DESIGN: Descriptive case-series. SUBJECTS: Seventy-five individuals with chronic stroke and 55 age-matched healthy subjects. METHODS: The English version of the Reintegration to Normal Living Index was translated into Chinese using standardized procedures, and then administered to both the stroke and control groups. The same instrument was administered again to the stroke subjects 1-2 weeks later. RESULTS: The Chinese version of the Reintegration to Normal Living Index had good internal consistency (Cronbach's α = 0.92) and test-retest reliability (intraclass coefficient = 0.87). The minimal detectable difference of the Index score was 14.8 (out of 100). Convergent validity of the Index was demonstrated by its significant association with Frenchay Activities Index (r = 0.439, p < 0.001) and Personal Wellbeing Index (r = 0.250, p = 0.033) scores among stroke subjects. The Reintegration to Normal Living Index score was significantly lower in the stroke group than in controls (p < 0.001), thus demonstrating discriminant validity. Factor analysis confirmed the two-factor structure of the Index, namely, daily functioning and perception of self. CONCLUSION: The Reintegration to Normal Living Index is a reliable and valid tool for assessing satisfaction with community reintegration among Chinese people with chronic stroke.

Effects of whole-body vibration on sensorimotor performance in people with Parkinson disease: a systematic review.

BACKGROUND: Earlier studies show that whole-body vibration (WBV) has beneficial effects on neuromuscular performance in older adults and may be a viable treatment option for people with Parkinson disease (PD). PURPOSE: This systematic review was aimed at determining whether WBV improves sensorimotor performance in people with PD. DATA SOURCES: The sources used in this review were MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Excerpta Medica database (EMBASE), the Cochrane Database of Systematic Reviews, and the Physiotherapy Evidence Database (PEDro) (last searched in April 2010). STUDY SELECTION: Randomized and nonrandomized controlled studies examining the effects of WBV in people with PD were selected. Six studies fulfilled the selection criteria and were included in this review. DATA EXTRACTION: The PEDro score was used to evaluate methodological quality. The effects of WBV on various sensorimotor outcomes were noted. DATA SYNTHESIS: Methodological quality was rated as good for 1 study (PEDro score of 6), fair for 4 studies (PEDro score of 4 or 5), and poor for 1 study (PEDro score of 2). Two studies showed that, compared with no intervention, WBV treatment led to significant reductions in tremor and rigidity, as measured with the Unified Parkinson Disease Rating Scale (UPDRS). The findings for other UPDRS cluster scores were conflicting, however. Two studies showed that longer-term WBV (3-5 weeks) did not result in better sensorimotor outcomes than conventional exercise training. LIMITATIONS: The studies reviewed here are limited by their methodological weaknesses and small, heterogeneous samples. CONCLUSIONS: There is insufficient evidence to prove or refute the effectiveness of WBV in enhancing sensorimotor performance in people with PD (ie, grade D recommendations). More good-quality trials are needed to establish the clinical efficacy of WBV in improving sensorimotor function in people with PD.

The effects of treadmill exercise training on hip bone density and tibial bone geometry in stroke survivors: a pilot study.

BACKGROUND: Individuals with stroke often sustain bone loss on the hemiparetic side and are prone to fragility fractures. Exercise training may be a viable way to promote bone mineral density (BMD) and geometry in this population. OBJECTIVE: This was a pilot study to evaluate the effects of a 6-month treadmill exercise program on hip BMD and tibial bone geometry in chronic stroke survivors. METHODS: Twenty-one individuals with chronic stroke, with a mean age of 64.5 years and mean post-stroke duration of 8.3 years participated in the study. The treatment group underwent a treadmill gait exercise program (two 1-hour sessions per week for 6 months), whereas the control group participated in their usual self-selected activities in the community. The primary outcomes were hip BMD and bone geometry of the midshaft tibia on the paretic side, whereas the secondary outcomes were gait velocity, endurance, leg muscle strength, balance self-efficacy, and physical activity level. Mann-Whitney U tests were used to compare the change in all outcome variables between the 2 groups after treatment. RESULTS: Significant between-group differences in change scores of tibial cortical thickness (P = .016), endurance ( P = .029), leg muscle strength on the paretic side (P < .001) and non-paretic side (P < .001), balance self-efficacy (P = .016), and physical activity level (P = .023) were found. CONCLUSION: The treadmill exercise program induced a modest improvement in tibial bone geometry in individuals with chronic stroke. Further studies are required to explore the optimal training protocol for promoting favorable changes in bone parameters following stroke.