Home-based multi-sensory and proximal strengthening program to improve balance in Charcot-Marie-Tooth disease Type 1A: A proof of concept study.

INTRODUCTION/AIMS: People with Charcot-Marie-Tooth Disease (CMT) frequently report problems with balance, which lead to an increased risk of falls. Evidence is emerging of training interventions to improve balance for people with CMT, but to date all have relied on clinic-based treatment and equipment. This proof-of-concept study explored whether a multi-modal program of proprioceptive rehabilitation and strength training can be delivered at home, to improve balance performance in people with CMT Type 1A. METHODS: Fourteen participants with CMT Type 1A were recruited into this randomized, two-arm study. Baseline assessments included measures of disease severity, posturography, physical function, and patient-reported outcome measurements. All participants received one falls education session. Participants were randomized to either 12 weeks of balance training or 12 weeks of usual activities. The intervention comprised a home-based, multi-sensory balance training and proximal strengthening program, supported by three home visits from a physiotherapist. RESULTS: Thirteen participants completed the study. The intervention was successfully implemented and well tolerated, with high participation levels. Functional measures of balance and walking showed strong effect sizes in favor of the training group. Posturography testing demonstrated moderate improvements in postural stability favoring the intervention group. Inconsistent changes were seen in lower limb strength measures. DISCUSSION: The intervention was feasible to implement and safe, with some evidence of improvement in balance performance. This supports future studies to expand this intervention to larger trials of pragmatic, home-delivered programs through current community rehabilitation services and supported self-management pathways.

Cerebral embolization during endovascular infrarenal, juxtarenal, and suprarenal aortic aneurysm repair, high-risk maneuvers, and associated neurologic outcomes.

BACKGROUND: Risk factors for postoperative cognitive decline after noncardiac surgery are multifactorial and poorly understood. Evidence suggests that perioperative microembolic damage to the brain on movement of wires and catheters during endovascular aortic procedures may play an important role. Endovascular aortic aneurysm repair requires invasive manipulation of wires and cannulas within the aorta, but research into cerebral emboli during aortic aneurysm repair and cognitive or neurologic injury is scarce and limited to thoracic aneurysms. This study prospectively studied embolic phenomena detected in the middle cerebral artery during infrarenal, juxtarenal, and thoracic endovascular aortic repair (TEVAR) and investigated links to delirium, stroke, and postoperative cognitive decline. METHODS: There were 60 patients who received continuous left-sided perioperative transcranial Doppler monitoring during endovascular aortic aneurysm repair (bifurcated graft for infrarenal aneurysm, n = 18; endovascular aneurysm sealing graft, n = 16; endovascular aneurysm sealing and renal "chimney" stent, n = 17; and thoracic aneurysm, n = 3). The procedure was time stamped for events such as stiff wire insertion and graft deployment. A battery of cognitive tests designed to test several cognitive domains were performed preoperatively and at 90 days postoperatively. RESULTS: TEVAR and chimney grafts demonstrated significantly greater numbers of total procedural emboli compared with standard bifurcated grafts (mean emboli, 36.2 and 13.39, respectively; bifurcated graft, 5.81; P < .05). The highest risk maneuvers were guidewire and pigtail catheter insertion. This was the case for all procedures including infrarenal aneurysm repair. A higher perioperative embolic load was associated with medium-term cognitive decline in list recall but not with incidence of delirium or stroke. Risk of cognitive decline did not relate to procedure type. Antiplatelet use failed to demonstrate a protective effect. CONCLUSIONS: Patients are at risk of cerebral emboli during several types of endovascular aortic surgery, although TEVAR remains the highest risk procedure. As yet, there are no validated protective measures available to prevent cerebral emboli and their associated risks of clinical and subclinical neurologic injury.

Evaluation of an early exercise intervention after thoracotomy for non-small cell lung cancer (NSCLC), effects on quality of life, muscle strength and exercise tolerance: randomised controlled trial.

Deterioration in exercise tolerance and impairment in quality of life (QoL) are common consequences of lobectomy. This study evaluates additional exercise and strength training after lung resection on QoL, exercise tolerance and muscle strength. Fifty-three (28 male) patients attending thoracotomy for lung cancer, mean age, range 64 (32-82) years; mean pack years (SD) 31.9 (26.8); BMI 25.6 (4.2); FEV1 2.0 (0.7) l were randomised to control (usual care) or intervention (twice daily training plus usual care). After discharge the intervention group received monthly home visits and weekly telephone calls, the control group received monthly telephone calls up to 12 weeks. Assessment pre-operatively, 5 day and 12 weeks post-operatively consisted of quadriceps strength using magnetic stimulation, 6 Minute Walking Distance (6MWD) and QoL-EORTC-QLQ-LC13. QoL was unchanged over 12 weeks; 6MWD showed significant deterioration at 5 days post-operatively compared with pre-operatively, mean difference (SD)-131.6 (101.8) m and -128.0 (90.7) m in active and control groups respectively (p=0.89 between groups) which returned to pre-operative levels by 12 weeks in both groups. Quadriceps strength over the 5 day in-patient period showed a decrease of -8.3 (11.3) kg in the control group compared to increase of 4.0 (21.2) kg in the intervention group (p=0.04 between groups). Strength training after thoracotomy successfully prevented the fall in quadriceps strength seen in controls, however, there was no effect on 6MWD or QoL. 6MWD returned to pre-operative levels by 12 weeks regardless of additional support offered.