Safety and efficacy of blood flow restriction exercise in individuals with neurological disorders: A systematic review.

OBJECTIVES: This systematic review evaluated the safety and efficacy of blood flow restriction exercise (BFRE) on skeletal muscle size, strength, and functional performance in individuals with neurological disorders (ND). METHODS: A literature search was performed in PubMed, CINAHL, and Embase. Two researchers independently assessed eligibility and performed data extraction and quality assessments. ELIGIBILITY CRITERIA: Study populations with ND, BFRE as intervention modality, outcome measures related to safety or efficacy. RESULTS: Out of 443 studies identified, 16 were deemed eligible for review. Three studies examined the efficacy and safety of BFRE, one study focused on efficacy results, and 12 studies investigated safety. Disease populations included spinal cord injury (SCI), inclusion body myositis (sIBM), multiple sclerosis (MS), Parkinson's disease (PD), and stroke. A moderate-to-high risk of bias was presented in the quality assessment. Five studies reported safety concerns, including acutely elevated pain and rating of perceived exertion levels, severe fatigue, muscle soreness, and cases of autonomic dysreflexia. Two RCTs reported a significant between-group difference in physical function outcomes, and two RCTs reported neuromuscular adaptations. CONCLUSION: BFRE seems to be a potentially safe and effective training modality in individuals with ND. However, the results should be interpreted cautiously due to limited quality and number of studies, small sample sizes, and a general lack of heterogeneity within and between the examined patient cohorts.

Effects of repetitive transcranial magnetic stimulation on recovery in lower limb muscle strength and gait function following spinal cord injury: a randomized controlled trial.

STUDY DESIGN: Randomized sham-controlled clinical trial. OBJECTIVES: The objective of this study is to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) compared to sham stimulation, on the development of lower limb muscle strength and gait function during rehabilitation of spinal cord injury (SCI). SETTING: SCI rehabilitation hospital in Viborg, Denmark. METHODS: Twenty individuals with SCI were randomized to receive rTMS (REAL, n = 11) or sham stimulation (SHAM, n = 9) and usual care for 4 weeks. rTMS (20 Hz, 1800 pulses per session) or sham stimulation was delivered over leg M1 Monday-Friday before lower limb resistance training or physical therapy. Lower limb maximal muscle strength (MVC) and gait function were assessed pre- and post intervention. Lower extremity motor score (LEMS) was assessed at admission and at discharge. RESULTS: One individual dropped out due to seizure. More prominent increases in total leg (effect size (ES): 0.40), knee flexor (ES: 0.29), and knee extensor MVC (ES: 0.34) were observed in REAL compared to SHAM; however, repeated-measures ANOVA revealed no clear main effects for any outcome measure (treatment p > 0.15, treatment × time p > 0.76, time p > 0.23). LEMS improved significantly for REAL at discharge, but not for SHAM, and REAL demonstrated greater improvement in LEMS than SHAM (p < 0.02). Similar improvements in gait performance were observed between groups. CONCLUSIONS: High-frequency rTMS may increase long-term training-induced recovery of lower limb muscle strength following SCI. The effect on short-term recovery is unclear. Four weeks of rTMS, when delivered in conjunction with resistance training, has no effect on recovery of gait function, indicating a task-specific training effect.

The treatment in the Danish suicide prevention clinics: a clinician perspective.

Background: Few qualitative studies have focused on clinicians' perspectives regarding treatment of suicidal people. Despite limited evidence and imperfect risk-assessment tools, the psychosocial therapy at the Danish suicide prevention clinics has been linked to reductions in numbers of repeated self-harm, deaths by suicide, and other causes. This merits an investigation into how clinicians describe their practice.Methods: Using a qualitative design, 10 semi-structured interviews were conducted and analyzed to describe the psychosocial therapy.Results: The practices that the therapists described could be categorized along four dichotomous continuums. These illustrated dilemmas encountered during treatment of suicidal patients: 1) intuitive vs. specific risk assessment, 2) meaningful vs. formal, 3) patient-oriented vs. therapist-oriented and 4) direct vs. indirect approach to suicide prevention.Conclusions: Treatment in the Danish Suicide Prevention Clinics is characterized by methodological flexibility and diversity and with an emphasis on a patient-oriented approach. Furthermore, clinicians balance knowledge available by switching between a direct and an indirect approach according to the perceived suicide risk. If suicide risk was perceived as high, they would administer a direct approach and if low, an indirect approach. Finally, there seems to be differences as to how effective therapeutic methodologies work in the practice of suicide prevention.

Feasibility of predicting improvements in motor function following SCI using the SCAR outcome measure: a retrospective study.

STUDY DESIGN: A retrospective study. OBJECTIVES: To assess improvement in volitional motor function after SCI, using The Spinal Cord Ability Ruler (SCAR) as a metric and investigate participant characteristics and recovery of motor functioning. SETTING: A highly-specialized SCI rehabilitation unit (Spinal Cord Injury Centre of Western Denmark, SCIWDK). METHODS: Retrospectively, data on all SCI patients admitted to SCIWDK between 1 January 1997 and 1 November 2018 were extracted from a database. The SCAR score (range: 0-100) was calculated by combining items from ISNCSCI and SCIM. RESULTS: Mean (95%CI) improvement in volitional motor function was of 17.2 (CI: 14.5-19.9) equal to an improvement of 43% from baseline after median 155 days in-hospital rehabilitation. Individuals with tetraplegia exerted larger improvement (mean difference of 8.9 (CI: 3.6-14.2) points) as compared to paraplegia. Male gender predicted better improvement (p < 0.03), as did no need for mechanical ventilation with a gain of 8.5 (CI: 1.8-15.3) points as compared to those in need. CONCLUSIONS: Overall mean improvement of 43% in volitional motor function was found in 84 in-hospitalized patients using SCAR as a metric at a highly-specialized SCI unit. Following factors; level-of-injury, gender, age, need of ventilation support predicted improvement in volitional motor function after a rehabilitation period. Results should be cautiously interpreted as a majority of hospitalized patients did not fulfill criteria for SCAR scoring. Prospectively designed studies with better internal validation and external validations are needed to confirm these findings.

Feasibility and safety of two weeks of blood flow restriction exercise in individuals with spinal cord injury.

CONTEXT: Reduced muscle strength and function are common after spinal cord injury (SCI). While low-load blood flow restriction exercise (BFRE) enhances muscle strength in healthy and clinical populations, its safety and feasibility in individuals with SCI remain underexplored. OBJECTIVES: To investigate the feasibility and safety of low-load BFRE in individuals with incomplete SCI. STUDY DESIGN: Case series. SETTING: SCI rehabilitation center. PARTICIPANTS: Six participants with motor incomplete SCI were enrolled in the study. INTERVENTION: A two-week BFRE intervention for the lower limbs was conducted twice weekly at 40% total arterial occlusion pressure, using 30-40% of 1-repetition maximum loads. OUTCOME MEASURES: Feasibility measures, specifically recruitment and eligibility rates and intervention acceptability, were collected. Blood pressure (BP) responses and specific coagulation markers for deep vein thrombosis (DVT) were assessed as safety measures. RESULTS: Recruitment and eligibility rates were 2.8% and 6.6% for individuals admitted for first-time rehabilitation (subacute SCI) and 8.3% and 13.9% for 4-week readmission rehabilitation stays (chronic SCI), respectively. Intervention acceptability was high, characterized by 95.8% training adherence and low-to-moderate self-reported pain levels. BP responses and changes in C-reactive protein, Fibrinogen, and D-dimer during the intervention remained within clinically acceptable levels. CONCLUSION: BFRE was feasible in an SCI rehabilitation setting despite a low recruitment rate. BFRE imposed no heightened risk of DVT or severe BP fluctuations in the present case series. Additionally, no severe adverse events occurred, and only mild complaints were reported. More extensive safety considerations warrant larger-scale exploration. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03690700.

Efficacy of repetitive transcranial magnetic stimulation for improving lower limb function in individuals with neurological disorders: A systematic review and meta-analysis of randomized sham-controlled trials.

OBJECTIVE: To determine the efficacy of repetitive transcranial magnetic stimulation vs sham stimulation on improving lower-limb functional outcomes in individuals with neurological disorders. DATA SOURCES: PubMed, CINAHL, Embase and Scopus databases were searched from inception to 31 March 2020 to identify papers (n = 1,198). Two researchers independently reviewed studies for eligibility. Randomized clinical trials with parallel-group design, involving individuals with neurological disorders, including lower-limb functional outcome measures and published in scientific peer-reviewed journals were included. DATA EXTRACTION: Two researchers independently screened eligible papers (n = 27) for study design, clinical population characteristics, stimulation protocol and relevant outcome measures, and assessed study quality. DATA SYNTHESIS: Studies presented a moderate risk of selection, attrition and reporting bias. An overall effect of repetitive transcranial magnetic stimulation was found for outcomes: gait (effect size [95% confidence interval; 95% CI]: 0.51 [0.29; 0.74], p = 0.003) and muscle strength (0.99 [0.40; 1.58], p = 0.001) and disorders: stroke (0.20 [0.00; 0.39], p = 0.05), Parkinson's disease (1.01 [0.65; 1.37], p = 0.02) and spinal cord injury (0.50 [0.14; 0.85], p = 0.006), compared with sham. No effect was found for outcomes: mobility and balance. CONCLUSION: Supplementary repetitive transcranial magnetic stimulation may promote rehabilitation focused on ambulation and muscle strength and overall lower-limb functional recovery in individuals with stroke, Parkinson's disease and spinal cord injury. Further evidence is needed to extrapolate these findings.

Feasibility and safety of 4 weeks of blood flow-restricted exercise in an individual with tetraplegia and known autonomic dysreflexia: a case report.

INTRODUCTION: Blood flow-restricted exercise (BFRE) appears to hold considerable potential in spinal cord injury (SCI) rehabilitation, due to its ability to induce beneficial functional changes and morphological alterations from low-intensity, low-load exercise. However, it remains unclear if this training approach is feasible and safe in individuals with autonomic dysreflexia (AD). CASE PRESENTATION: A 23-year-old male with traumatic, cervical (C6), motor-complete (AIS: B) SCI and diagnosed AD completed eight sessions of BFRE for the upper extremities over 4 weeks. Blood pressure and heart rate recordings and perceptual pain responses were collected repeatedly during exercise. Blood samples were drawn pre- and post-training. Training was carried out in a neurorehabilitation hospital setting with appertaining medical staff readiness, and was supervised by a physiotherapist with expertise in AD in general as well as prior knowledge of the present patient's triggers and symptoms. Four incidences of AD (defined as systolic blood pressure increase >20 mmHg) were recorded across all training sessions, of which one was symptomatic. The patient's blood profile did not change considerably from pre- to post-training sessions. Self-reported average pain during training corresponded from "mild" to "moderate". DISCUSSION: The patient was able to perform 4 weeks of BFRE, but encountered episodes of AD. Similarly, two AD episodes were registered during a single conventional, free-flow resistance training session. Evidence from clinically controlled safety studies is needed in order to establish if and how BFRE can be applied in a rehabilitation strategy in SCI individuals with neurological level of injury at or above T6 level.

Pain assessment in hospitalized spinal cord injured patients - a controlled cross-sectional study.

Background and aims Following spinal cord injury (SCI), a majority of individuals may develop neuropathic pain, which further reduces quality of life. Pain is difficult to treat by medication; in fact, medication overuse may aggravate neuropathic pain in SCI by causing central sensitization (CS): a mechanism of hyper-reactivity of the dorsal horn neurons in the spinal cord with amplified cerebral pain response. The purpose of this study was to examine the presence of neuropathic pain and CS above the spinal lesion in SCI, and to investigate whether injury characteristics or medication influenced pain response. Methods Twenty-four SCI patients with various injury characteristics (eight subacute, traumatic injuries, eight chronic, traumatic injuries, eight non-traumatic injuries) and 12 able-bodied controls underwent sensory testing:pressure algometry, Von Frey filaments (sensitivity), and repetitive pinprick stimulation (pain windup). SCI participants also fulfilled a modified version of the McGill Pain Questionnaire. Data were analyzed regarding (i) SCI patients compared with controlgroup and (ii) SCI subgroup comparison (grouped by a) injury characteristics and (b) intake of analgesics, where low-medicated subgroup were prescribed only non-opioids and high-medicated potent opioids). Results Neuropathic pain was present in 21 of 24 SCI patients. Chronic and non-traumatic SCI patients reported considerably higher present pain intensity than sub-acute traumatic SCI patients on a five-point scale (3.13±0.99, 1.75±1.75 and 0.13±0.35, respectively, p<0.005). Reduced pressure pain detection thresholds (PPDT) were found in SCI patients at several supra-lesional anatomical points compared to controls. Contrarily, tactile detection thresholds were higher in SCI. SCI subgroup analyses showed that i) the low-medicated SCI subgroup displayed significantly lower PPDT compared to the high-medicated subgroup, ii) pain-windup was present in all subgroups although the sub-acute and non-traumatic subgroups displayed lesser pain windup than controls, and the chronic SCI subgroup mainly displayed higher pain windup. Conclusions The reduced PPDT found above lesion suggests the presence of CS in SCI. However, findings regarding SCI subgroup comparison did not support our hypothesis that more medication leads to increased CS. Implications The development of CS may complicate diagnosis and pain treatment following SCI. Prospective studies of SCI with a healthy control group are needed.

[Neuromodulation in spinal cord injury rehabilitation].

Suffering a spinal cord injury is a devastating event often entailing a significant and demanding inpatient rehabilitation regime to improve the level of functioning post-injury. Neuromodulation has been applied in spinal cord injury rehabilitation for decades and carries promise for ameliorating the chronic complications associated with lesions of the spinal cord. Conventional methods of rehabilitation may be augmented by different modes of neuromodulation offering better rehabilitation outcomes, and combining techniques not currently in clinical use may convey additional benefits.

Mindfulness is positively related to socioeconomic job status and income and independently predicts mental distress in a long-term perspective: Danish validation studies of the Five-Factor Mindfulness Questionnaire.

The Five Factor Mindfulness Questionnaire (FFMQ) measures 5 factor-analytically derived mindfulness aspects (Observe, Describe, Non-Judgment, Non-Reactivity, and Acting with Awareness) and is commonly used as an indicator of mindfulness in population surveys and studies of mindfulness-based interventions (MBI). Outside MBI, FFMQ scores are hypothesized to reflect relatively stable human dispositions of importance to psychological health. However, the long-term test-retest reliability of FFMQ scores is virtually untested and it remains unknown whether FFMQ scores predict psychological health after controlling for standardized socioeconomic status classifications. First, we focused on psychometric validation of the FFMQ translated to Danish in a randomly invited healthy and nonmeditating adult community sample (N = 490). Confirmatory factor analyses primarily supported a four-factor construct excluding the Observe facet. The four-factor model showed adequate composite reliability, convergent validity and satisfactory-excellent internal consistency, Cronbach αs = .72-.91. Structural equation modeling revealed that FFMQ Total scores were positively related to income and socioeconomic status but independently predicted psychological distress and mental health scores, respectively, after controlling for age, gender, body mass index, socioeconomic job classification, stressful life events, and social desirability, ß = -.24-.29, ps < .001. Second, FFMQ scores showed adequate short-term (two weeks) test-retest reliability among 99 healthy university students, Spearman's ρs ≥ .82. Finally, all FFMQ mean scores showed satisfactory test-retest reliability across a long-term (six months) interval (N = 407), intraclass correlation coefficients ≥.74. We recommend the Danish FFMQ for further use. The Observe facet should be interpreted with caution. Remaining FFMQ facet scores comprise an internally consistent four-dimensional construct reflecting long-term-reliable human dispositions of independent significance for predicting mental health. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Whiplash injury results in sustained impairments of cervical muscle function: A one-year prospective, controlled study.

OBJECTIVE: To investigate the temporal development of neck muscle function following whiplash injuries. DESIGN: A 1-year prospective, controlled observational study. SUBJECTS: A total of 141 individuals exposed to whiplash injury due to rear-end vehicle collisions and 40 age- and sex-matched controls with acute ankle distortion. METHODS: Neck muscle strength and endurance during cervical flexion and extension were measured at 1 week, 1 month, 3 months, 6 months and 1 year after injury. RESULTS: Notable reductions (23-30%) of neck strength in both directions were seen for whiplash-exposed subjects at all time points, compared with controls. Also, extensor endurance was reduced at 1 week, 1 month, 3 months, 6 months* and 1 year* (*non-significant). Within the whiplash group, non-recovered individuals (individuals who had not returned to pre-injury work capacity at one year) displayed ~50% reductions in cervical strength in both directions at all time points, compared with recovered whiplash individuals. CONCLUSION: Cervical muscular functioning is impaired for at least one year after whiplash injury, well beyond the time course of recovery of neck mobility and pain sensations. In whiplash-exposed individuals, non-recovery is associated with considerable muscular weakness. There is a need for increased clinical focus on early neck function after whiplash injury.

[Intersection syndrome in a tetraplegic hand cyclist].

Wrist tendinopathies are common overuse injuries in athletes and often associated with activities such as rowing, riding or racket sports. Correctly diagnosing the various tendinopathies is essential for management of cases refractory to initial treatment. Easily mistaken for de Quervain's tenosynovitis, the intersection syndrome may be effectively managed by simple taping negating the need for corticosteroid injection and tendon release surgery. We present an unusual case report of intersection syndrome in a tetraplegic hand cyclist following a 24-hour endurance race.