Age-independent benefits of postoperative rehabilitation during chemoradiotherapy on functional outcomes and survival in patients with glioblastoma.

PURPOSE: To investigate the impact of early and continuous postoperative inpatient rehabilitation during chemoradiotherapy on functional outcomes and overall survival (OS) in patients with glioblastoma (GBM), particularly in different age groups. METHODS: This retrospective cohort study at a university hospital (2011-2016) included 75 of 119 consecutive patients newly diagnosed with GBM who underwent standardized treatment and postoperative rehabilitation. Patients were divided into older (≥ 65 years, n = 45) and younger (< 65 years, n = 30) groups, engaging in a 50-day rehabilitation program. We assessed rehabilitation progress, Barthel Index (BI), Brunnstrom Recovery Stage (BRS), adverse events, and OS. BI at discharge and survival were analyzed using multivariate and Cox regression models, respectively. RESULTS: The mean age was 72.5 ± 6.3 and 52.4 ± 7.8 years in the older and younger groups, respectively. Both groups demonstrated significant improvements in BI and BRS. Despite more adverse events in the older group, no significant difference existed in median OS (older group: 18.7 months vs. younger group: 18.3 months, p = 0.87). Early walking training, reduced fatigue during chemoradiotherapy, and high Karnofsky Performance Status at admission significantly impacted the BI at discharge. Cox regression analysis identified the BI at discharge as a significant predictor of survival (hazard ratio [HR] 0.98, 95% confidence interval [CI] 0.97-0.99, p = 0.008). CONCLUSION: Integrated rehabilitation improves functional outcomes, and enhanced ADL at discharge is associated with improved survival outcomes in patients with GBM, regardless of age. This highlights the need for personalized rehabilitation in treatment protocols. Further prospective studies are warranted to confirm these findings.

A new method for detecting unilateral spatial neglect with tracing tasks using the Rey-Osterrieth complex figure: a pilot study.

PURPOSE: To explore efficacy of the "Rey-Osterrieth complex figure (ROCF) tracing task" as a new test to detect unilateral spatial neglect (USN). METHODS: Subjects were 40 healthy control (HC) and 20 right brain-damaged patients with (USN + , n = 10) or without USN (USN - , n = 10). After the ROCF copying task, the tracing task was performed under conditions that did not leave any tracing lines on the sample figure. Evaluation used the conventional 36-point scoring system, laterality index (LI) as the ratio of the left and right structure scores, and the number of overlaps for each of the left and right structures scored. RESULTS: In the tracing task, USN + showed a lower LI than HC. Furthermore, left-sided neglect was sometimes more evident than in the copying task. Regarding the total overlapping score, USN + showed a greater score than HC. The right-sided overlapping scores in USN + and USN - were also greater than that in HC. In the right brain-damaged subjects, clinically meaningful correlations were not found between evaluations in the ROCF tracing task and in conventional USN screening tests. Receiver-operating-characteristic analysis to test the power of detection showed moderate performance for the tracing LI (AUC = 0.76, 95% CI = 0.54-0.97), which was greater than that of other tests. Further, the total overlapping score in the tracing task showed sensitivity 0.9 (highest among the tests performed), specificity 0.5, and AUC 0.68 (95% CI = 0.43-0.92). CONCLUSION: The ROCF tracing task might be a convenient method to detect USN and to reveal the extent of spatial working memory impairment.

Effects of lower limb segmental muscle vibration on primary motor cortex short-latency intracortical inhibition and spinal excitability in healthy humans.

We examined the effects of lower limb segmental muscle vibration (SMV) on intracortical and spinal excitability in 13 healthy participants (mean age: 34.9 ± 7.8 years, 12 males, 1 female). SMV at 30 Hz was applied to the hamstrings, gastrocnemius, and soleus muscles for 5 min. Paired-pulse transcranial magnetic stimulation protocols were used to investigate motor-evoked potential (MEP)  amplitude, short-interval intracortical inhibition (SICI) and short-interval intracortical facilitation (SICF) from the abductor hallucis muscle (AbdH). These assessments were compared to the results of a control experiment (i.e., non-vibration) in the same participants. F-waves were evaluated from the AbdH on the right (vibration side) and left (non-vibration side) sides, and we calculated the ratio of the F-wave amplitude to the M-response amplitude (F/M ratio). These assessments were obtained before, immediately after, and 10, 20, and 30 min after SMV. For SICI, there was no change immediately after SMV, but there was a decrease over time (before vs. 30 min after, p = 0.021; immediately after vs. 30 min after, p = 0.015). There were no changes in test MEP amplitude, SICF, or the F/M ratio. SMV causes a gradual decrease in SICI over time perhaps owing to long-term potentiation. The present results may have implications for the treatment of spasticity.

Quantitative measurement of resistance force and subsequent attenuation during passive isokinetic extension of the wrist in patients with mild to moderate spasticity after stroke.

BACKGROUND: Spasticity is evaluated by measuring the increased resistance to passive movement, primarily by manual methods. Few options are available to measure spasticity in the wrist more objectively. Furthermore, no studies have investigated the force attenuation following increased resistance. The aim of this study was to conduct a safe quantitative evaluation of wrist passive extension stiffness in stroke survivors with mild to moderate spastic paresis using a custom motor-controlled device. Furthermore, we wanted to clarify whether the changes in the measured values could quantitatively reflect the spastic state of the flexor muscles involved in the wrist stiffness of the patients. MATERIALS AND METHODS: Resistance forces were measured in 17 patients during repetitive passive extension of the wrist at velocities of 30, 60, and 90 deg/s. The Modified Ashworth Scale (MAS) in the wrist and finger flexors was also assessed by two skilled therapists and their scores were averaged (i.e., average MAS) for analysis. Of the fluctuation of resistance, we focused on the damping just after the peak forces and used these for our analysis. A repeated measures analysis of variance was conducted to assess velocity-dependence. Correlations between MAS and damping parameters were analyzed using Spearman's rank correlation. RESULTS: The damping force and normalized value calculated from damping part showed significant velocity-dependent increases. There were significant correlations (ρ = 0.53-0.56) between average MAS for wrist and the normalized value of the damping part at 90 deg/s. The correlations became stronger at 60 deg/s and 90 deg/s when the MAS for finger flexors was added to that for wrist flexors (ρ = 0.65-0.68). CONCLUSIONS: This custom-made isokinetic device could quantitatively evaluate spastic changes in the wrist and finger flexors simultaneously by focusing on the damping part, which may reflect the decrease in resistance we perceive when manually assessing wrist spasticity using MAS. Trial registration UMIN Clinical Trial Registry, as UMIN000030672, on July 4, 2018.

Combination therapy with repetitive facilitative exercise program and botulinum toxin type A to improve motor function for the upper-limb spastic paresis in chronic stroke: A randomized controlled trial.

STUDY DESIGN: An open-label, randomized, controlled, observer-blinded trial. INTRODUCTION: Repetitive facilitative exercise (RFE) is a movement therapy to recover from hemiparesis after stroke. However, improvement is inhibited by spasticity. Recently, botulinum toxin type A (BoNT-A) injection has been shown to reduce spasticity. PURPOSE: To examine the combined effect of an RFE program and BoNT-A treatment on upper-limb spastic paresis in chronic stroke. METHODS: Forty chronic stroke inpatients with upper-limb spastic paresis (Brunnstrom stage ≥III and Modified Ashworth Scale [MAS] score ≥1) were enrolled. Subjects were randomized into 2 groups of 20 each and received 4 weeks of treatment. The intervention group received RFE and BoNT-A injection; the control group underwent RFE only. Assessments were performed at baseline and at study conclusion. The primary outcome was change in Fugl-Meyer Assessment score for the upper extremity (FMA). The Action Research Arm Test (ARAT), active range of motion, Box and Block Test, and MAS were also evaluated. RESULTS: All participants completed this study. After 4 weeks, the intervention group evidenced a significantly greater increase in FMA score (median 11.0 [range 4-20]) than the control group (median 3.0 [range 0-9]) (P < .01, r = 0.79); as well as improvements in the other measures such as ARAT (median 12.5 [range 4-22] vs 7 [0-13]) (P < .01, r = 0.6), and MAS in the elbow flexors (median -1.5 [range -2 to 0] vs -1 [-2 to 0]) (P < .01, r = 0.45). DISCUSSION: A high degree of repetitive volitional movement induced by the facilitative technique with concomitant control of spasticity by BoNT-A injection might increase efficiency of motor learning with continuous movement of the affected upper-limb. CONCLUSIONS: The combination of RFE and BoNT-A for spastic paresis might be more effective than RFE alone to improve upper-limb motor function and to lessen impairment in chronic stroke.

Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial.

BACKGROUND: Our group developed a rehabilitation robot to assist with repetitive, active reaching movement of a paretic upper extremity. The robot is equipped with a servo motor-controlled arm-weight support and works in conjunction with neuromuscular electrical stimulation and vibratory stimulation to facilitate agonist-muscle contraction. In this before-and-after pilot study, we assessed the feasibility of applying the robot to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke. METHODS: We enrolled 6 patients with chronic stroke and hemiparesis who, while sitting and without assistance, could reach 10 cm both sagitally and vertically (from a starting position located 10 cm forward from the patient's navel level) with the affected upper extremity. The patients were assigned to receive reaching exercise intervention with the robot (Yaskawa Electric Co., Ltd. Fukuoka, Japan) for 2 weeks at 15 min/day in addition to regular occupational therapy for 40 min/day. Outcomes assessed before and after 2 weeks of intervention included the upper extremity component of the Fugl-Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and, during reaching movement, kinematic analysis. RESULTS: None of the patients experienced adverse events. The mean score of UE-FMA increased from 44.8 [SD 14.4] to 48.0 [SD 14.4] (p = 0.026, r = 0.91), and both the shoulder-elbow and wrist-hand scores increased after 2-week intervention. An increase was also observed in ARAT score, from mean 29.8 [SD 16.3] to 36.2 [SD 18.1] (p = 0.042, r = 0.83). Kinematic analysis during the reaching movement revealed a significant increase in active range of motion (AROM) at the elbow, and movement time tended to decrease. Furthermore, trajectory length for the wrist ("hand path") and the acromion ("trunk compensatory movement") showed a decreasing trend. CONCLUSIONS: This robot-assisted modality is feasible and our preliminary findings suggest it improved motor control and motor function of the hemiparetic upper extremity in patients with chronic stroke. Training with this robot might induce greater AROM for the elbow and decrease compensatory trunk movement, thus contributing to movement efficacy and efficiency. Trial registration UMIN Clinical Trial Registry, as UMIN000018132, on June 30, 2015. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000020398.

Development of Quality Indicators of Stroke Centers and Feasibility of Their Measurement Using a Nationwide Insurance Claims Database in Japan　­ J-ASPECT Study ­

BACKGROUND: We aimed to develop quality indicators (QIs) related to primary and comprehensive stroke care and examine the feasibility of their measurement using the existing Diagnosis Procedure Combination (DPC) database. METHODS AND RESULTS: We conducted a systematic review of domestic and international studies using the modified Delphi method. Feasibility of measuring the QI adherence rates was examined using a DPC-based nationwide stroke database (396,350 patients admitted during 2013-2015 to 558 hospitals participating in the J-ASPECT study). Associations between adherence rates of these QIs and hospital characteristics were analyzed using hierarchical logistic regression analysis. We developed 17 and 12 measures as QIs for primary and comprehensive stroke care, respectively. We found that measurement of the adherence rates of the developed QIs using the existing DPC database was feasible for the 6 QIs (primary stroke care: early and discharge antithrombotic drugs, mean 54.6% and 58.7%; discharge anticoagulation for atrial fibrillation, 64.4%; discharge antihypertensive agents, 51.7%; comprehensive stroke care: fasudil hydrochloride or ozagrel sodium for vasospasm prevention, 86.9%; death complications of diagnostic neuroangiography, 0.4%). We found wide inter-hospital variation in QI adherence rates based on hospital characteristics. CONCLUSIONS: We developed QIs for primary and comprehensive stroke care. The DPC database may allow efficient data collection at low cost and decreased burden to evaluate the developed QIs.

Quality Management Program of Stroke Rehabilitation Using Adherence to Guidelines: A Nationwide Initiative in Japan.

BACKGROUND AND AIM: In recent years, interest in the quality of medical care has rapidly increased worldwide. However, quality indicators that contribute to establishing standard treatment in stroke medicine, especially rehabilitation, are not well-developed in Japan. Japan has established Kaifukuki (convalescent) rehabilitation wards, and the development of quality indicators for stroke rehabilitation in the convalescent phase is an urgent issue. METHODS: We first reviewed the literature regarding quality indicators for stroke rehabilitation. Next, we extracted candidate indicators from identified reports and guidelines and surveyed educational hospitals certified by the Japanese Association of Rehabilitation Medicine. On the basis of the survey results, we reevaluated the suitability of the proposed indicators in discussions with an expert panel. RESULTS: The questionnaire survey highlighted several important items that revealed there is room for improvement in adherence. For stroke rehabilitation in the convalescent phase, we adopted 15 indicators that were feasible as indicators to be used for comparisons between facilities, based on scoring by and opinions of the expert panel. These indicators measured structure (2 indicators), process (5 indicators), and outcome (8 indicators). CONCLUSION: This is the first study to establish quality indicators to standardize stroke rehabilitation in Japan. We developed this set of 15 indicators using an evidence-based approach. However, many tasks remain for continuous quality improvement.

Effects of Repetitive Facilitative Exercise on Spasticity in the Upper Paretic Limb After Subacute Stroke.

BACKGROUND: Repetitive facilitative exercise is an effective method for recovery of the affected limb in stroke patients. However, its effects on spasticity are unknown. We aimed to determine the effects of repetitive facilitative exercise on spasticity using the Modified Ashworth Scale (MAS) and the F-wave, and to determine the relationship between the changes in spasticity and functional recovery of the hemiplegic upper limb. METHODS: Subacute stroke patients underwent repetitive facilitative exercise (n = 11) or conventional rehabilitation (n = 8) for 4 weeks. We investigated spasticity and functional recovery in a hemiplegic upper limb retrospectively. The MAS, F-wave, Fugl-Meyer Assessment (FMA), and the Action Research Arm Test (ARAT) were assessed immediately before and after the 4-week session. RESULTS: Repetitive facilitative exercise did not change the MAS and decreased F persistence and the F amplitude ratio, and improved both the FMA and the ARAT for the affected upper limb. The reduction of F-wave parameters was not correlated with the improvements in the FMA and ARAT in the repetitive facilitative exercise group. Conventional rehabilitation had no effect on the MAS, F-wave parameters, FMA, or the ARAT. CONCLUSIONS: Repetitive facilitative exercise decreases spinal motoneuron excitability and promotes functional recovery. However, there was no correlation between the change in spinal motoneuron excitability and the improvement of upper-limb function. The present results suggest that repetitive facilitative exercise is useful for treating spasticity in the subacute phase of stroke.

Use of an arm weight-bearing combined with upper-limb reaching apparatus to facilitate motor paralysis recovery in an incomplete spinal cord injury patient: a single case report.

[Purpose] Training using an arm weight-bearing device combined with upper-limb reaching apparatus to facilitate motor paralysis recovery, named the "Reaching Robot", as well as Repetitive Facilitation Exercise were applied to a patient with severe impairment of the shoulder and elbow due to incomplete spinal cord injury and the effects were examined. [Subjects and Methods] A 66-year-old man with incomplete spinal cord injury participated in an upper extremity rehabilitation program involving a Reaching Robot. The program was comprised of active motor suspension, continuous low amplitude neuromuscular electrical stimulation and functional vibratory stimulation, as well as Repetitive Facilitation Exercise combined with continuous low amplitude neuromuscular electrical stimulation. This protocol used a crossover design following an A1-B1-A2-B2. "A" consisted of 2 weeks of Repetitive Facilitation Exercise, and "B" consisted of 2 weeks of Reaching Robot training. [Results] Improvements were observed after all sessions. Active range of motion for shoulder flexion improved after 2 weeks of Reaching Robot sessions only. There were no adverse events. [Conclusion] Reaching Robot training for severe paretic upper-extremity after incomplete spinal cord injury was a safe and effective treatment. Reaching Robot training may be useful for rehabilitation of paretic upper-extremity after incomplete spinal cord injury.

Short-term effects of physiotherapy combining repetitive facilitation exercises and orthotic treatment in chronic post-stroke patients.

[Purpose] This study investigated the short-term effects of a combination therapy consisting of repetitive facilitative exercises and orthotic treatment. [Subjects and Methods] The subjects were chronic post-stroke patients (n=27; 24 males and 3 females; 59.3 ± 12.4 years old; duration after onset: 35.7 ± 28.9 months) with limited mobility and motor function. Each subject received combination therapy consisting of repetitive facilitative exercises for the hemiplegic lower limb and gait training with an ankle-foot orthosis for 4 weeks. The Fugl-Meyer assessment of the lower extremity, the Stroke Impairment Assessment Set as a measure of motor performance, the Timed Up & Go test, and the 10-m walk test as a measure of functional ambulation were evaluated before and after the combination therapy intervention. [Results] The findings of the Fugl-Meyer assessment, Stroke Impairment Assessment Set, Timed Up & Go test, and 10-m walk test significantly improved after the intervention. Moreover, the results of the 10-m walk test at a fast speed reached the minimal detectible change threshold (0.13 m/s). [Conclusion] Short-term physiotherapy combining repetitive facilitative exercises and orthotic treatment may be more effective than the conventional neurofacilitation therapy, to improve the lower-limb motor performance and functional ambulation of chronic post-stroke patients.

Intra-rater and inter-rater reliability of the portable gait rhythmogram in post-stroke patients.

[Purpose] Gait analysis, such as portable gait rhythmogram (PGR) provides objective information that helps in the quantitative evaluation of human locomotion. The purpose of this study was to assess the reliability of PGR in post-stroke patients. [Subjects and Methods] Two raters (A and B) examined 44 post-stroke patients. To assess intra-rater reliability, rater A tested subjects on three separate occasions (Days 1, 2, and 3). To assess inter-rater reliability, raters A and B independently tested participants on the same occasion (Day 3). [Results] There was no significant systematic bias between test occasions or raters. Intraclass correlation coefficient values were 0.93-0.97 for intra-rater reliability at both the comfortable speed and maximum speed, and 0.97-0.98 (comfortable speed) and 0.87-0.99 (maximum speed) for inter-rater reliability. The standard error was 1.25-1.49 (comfortable speed) and 1.62-1.77 (maximum speed) for intra-rater investigation, and 1.04-1.32 (comfortable speed) and 0.91-1.26 (maximum speed) for inter-rater investigation. At the 90% confidence level, the minimum detectable change ranged from 2.9-4.1%, and the error of an individual's score at a given time point ranged from ±2.1-2.9%. [Conclusion] Based on this excellent reliability of the PGR in post-stroke patients, it can be recommended as a simple test of gait analysis in this population.

Outcomes of repetitive facilitation exercises in convalescent patients after stroke with impaired health status.

OBJECTIVE: To investigate the impact of stroke on health status and the effects of repetitive facilitation exercises (RFEs) for convalescent patients after stroke. METHODS: The study was a prospective observational study of patients enrolled in an RFE programme. Between April 2008 and March 2012, 468 patients with stroke were enrolled in an intensive, comprehensive RFE programme. Patients participated in this interdisciplinary programme for 12 weeks, for an average of 5 hours per week. Before and immediately after the programme, several measures of rehabilitation outcomes and health-related quality-of-life were evaluated. RESULTS: At baseline, most patients (95.4%) had modified Rankin scale scores of 3-5. Their health-related quality-of-life was significantly impaired, with physical and mental component summary scores on the Short Form 36-item questionnaire (SF-36) of 30.7 and 35.8, respectively. After the RFE programme, all outcome measures improved significantly. CONCLUSIONS: The results demonstrate that convalescent patients after stroke may benefit substantially from RFE programmes in stroke rehabilitation centres, even when patients have impaired health status or high levels of healthcare utilization. Thus, an RFE programme is a simple yet highly effective means to improve rehabilitation outcomes and health-related quality-of-life, with a relatively low dropout rate.

Effects of repetitive facilitative exercise with neuromuscular electrical stimulation, vibratory stimulation and repetitive transcranial magnetic stimulation of the hemiplegic hand in chronic stroke patients.

AIM: Repetitive facilitative exercise (RFE) is a developed approach to the rehabilitation of hemiplegia. RFE can be integrated with neuromuscular electrical stimulation (NMES), direct application of vibratory stimulation (DAVS) and repetitive transcranial magnetic stimulation (rTMS). The aims of the present study were to retrospectively compare the effects of RFE and NMES, DAVS with those of RFE and rTMS, and to determine the maximal effect of the combination of RFE with NMES, DAVS, rTMS and pharmacological treatments in stroke patients. SUBJECTS AND METHODS: Thirty-three stroke patients were enrolled and divided into three groups: 15 who received RFE with rTMS (4 min) (TMS4 alone), 9 who received RFE with NMES, DAVS (NMES, DAVS alone) and 9 who received RFE with NMES, DAVS and rTMS (10 min) (rTMS10 + NMES, DAVS). The subjects performed the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT) before and after the 2-week session. The 18 patients in the NMES, DAVS alone and rTMS10 + NMES, DAVS group underwent the intervention for 4 weeks. RESULT: There were no significant differences in the increases in the FMA, ARAT scores in the three groups. The FMA or ARAT scores in the NMES, DAVS alone and the rTMS10 + NMES, DAVS group were increased significantly. The FMA and ARAT scores were significantly improved after 4 weeks in the NMES, DAVS alone group. DISCUSSION: RFE with NMES, DAVS may be more effective than RFE with rTMS for the recovery of upper-limb function. Patients who received RFE with NMES, DAVS and pharmacological treatments showed significant functional recovery.

Repetitive facilitative exercise under continuous electrical stimulation for severe arm impairment after sub-acute stroke: a randomized controlled pilot study.

OBJECTIVE: To investigate the effectiveness of repetitive facilitative exercise (RFE) under surface neuromuscular electrical stimulation (NMES) in patients with post-stroke hemiplegia. METHODS: This randomized, controlled, observer-blinded, pilot trial randomized 27 adults with severe arm impairment [Fugl-Meyer Arm scale (FMA) ≤ 20] due to stroke of 3-13 weeks duration into three groups and provided treatment on a 4-week, 40 minutes/day, 5 days/week schedule. The RFE-under-NMES group were given 100-150 repetitions of standardized movements of shoulder, elbow and wrist joints of their affected arm with concurrent low-amplitude NMES for each corresponding musculature. The RFE group was given the same exercise regimen but without NMES. The control group was treated with a conventional arm rehabilitation programme without NMES. FMA was assessed at baseline and 4 weeks. RESULTS: All 27 participants (nine in each group) completed the trial. At 4 weeks, the RFE-under-NMES group evidenced significantly greater improvement compared with the control group on the FMA (p = 0.003), but not with the RFE group (p = 0.092). The RFE group showed improvement compared with the control group, but it was not significant (p = 0.199). CONCLUSIONS: RFE under NMES is feasible in clinical settings and may be more effective than conventional rehabilitation in lessening arm impairment after sub-acute stroke.

Combined repetitive facilitative exercise under continuous neuromuscular electrical stimulation and task-oriented training for hemiplegic upper extremity during convalescent phase after stroke: before-and-after feasibility trial.

Introduction: Whereas repetitive facilitative exercise (RFE) affects primarily recovery of motor impairment after stroke, task-oriented training (TOT) focuses on facilitating daily use of the affected upper extremity. However, feasibility of combined RFE and TOT has not been reported. We originated "task-oriented RFE," as a new combination therapy for patients with hemiplegic upper extremity after subacute stroke, to examine its feasibility in convalescent rehabilitation wards. Methods: This is a before-and-after pilot study. Eight patients with hemiplegic upper extremity after subacute stroke received the task-oriented RFE program for 6 weeks at 80 min per day (20-60 min of TOT applied after 60-20 min of RFE under continuous neuromuscular electrical stimulation) in a convalescent rehabilitation ward. In the current program, we introduced the Aid for Decision-making in Occupation Choice (ADOC) iPad application as a goal-setting method for determining tasks. Feasibility was assessed with adherence to the protocol, adverse events in response to the intervention, and preliminary efficacy. Motor functions, amount of use and quality of movement in the hemiparetic upper extremity, and satisfaction of the patients were evaluated with Fugl-Meyer Assessment (FMA), the Action Research Arm Test (ARAT), the motor activity log (MAL) for the amount of use (AOU) and quality of movement (QOM) of the paralyzed hand, and ADOC. Results: All participants accomplished the program, which was implemented as originally planned; neither nonattendance nor an adverse event occurred during the study. Favorable outcomes were obtained with all measures; mean changes in FMA, ARAT in the dominant hand, MAL-AOU, and MAL-QOM were greater than minimal clinically important differences. Mean changes in ADOC were greater than the minimal detectable change. Discussion: The task-oriented RFE program was safe, well-tolerated, beneficial, and feasible within 80 min a day of occupational therapy, which means also within the procedural constraints of the Japanese health insurance system during the convalescent phase. Future studies are warranted to examine whether combined RFE and TOT enhances the efficacies of each program alone.

Disorders of Consciousness after Subacute Stroke Might Partly be Caused by Carnitine Deficiency: Two Case Reports.

Background: Carnitine is a vital human nutrient. Although there are many reports on carnitine deficiency, most studies have been conducted on children, patients with severe mental and physical disabilities, epileptic patients, patients with liver cirrhosis, and dialysis patients. To the best of our knowledge, there are no reports on carnitine administration for disorders of consciousness after stroke. We report two such cases in which carnitine administration improved disorders of consciousness. Cases: Case 1 was a woman in her sixties who was admitted to our rehabilitation center 4 months after the onset of subarachnoid hemorrhage. After admission, her disorders of consciousness worsened even though she was actively undergoing rehabilitation. Suspecting carnitine deficiency, we administered 1500 mg/day of L-carnitine, which resulted in improvement of her disorders of consciousness and disappearance of symptoms such as convulsions. Case 2 was a man in his thirties who was admitted to our rehabilitation center 5 months after the onset of cerebral hemorrhage. During active rehabilitation, he suffered worsening disorders of consciousness, convulsions, and cramps. We found carnitine deficiency with a blood carnitine concentration of 21 mg/dL, so we administered 1500 mg/day of L-carnitine; symptoms of disorders of consciousness and convulsions then improved. Discussion: It is possible that carnitine deficiency has been overlooked in some patients in rehabilitation wards, and measurement of ammonia might facilitate its detection. Because carnitine deficiency can interfere with active rehabilitation, nutritional management with attention to carnitine deficiency could be important during rehabilitation.

Repetitive facilitative exercise under continuous electrical stimulation for recovery of pure motor isolated hand palsy after infarction of the "hand knob" area: A case report.

PURPOSE: Pure motor isolated hand palsy (PMIHP) following infarction of the "hand knob" area is a rare entity in stroke. PMIHP usually recovers within the first few days, but there are rare cases where patients do not recover rapidly. Herein, we report a case of residual PMIHP in which repetitive facilitative exercise under concurrent low-amplitude continuous neuromuscular electrical stimulation ("RFE-under-cNMES") was introduced to improve hand function. CASE DESCRIPTION: A 65-year-old man with PMIHP (30 days after onset) participated in a rehabilitation program involving RFE-under-cNMES. This protocol followed an A1-B1-A2-B2 schedule, where the "A"-period consisted of RFE-under-cNMES ("A1," 2 weeks; "A2," 1 week), and the "B"-period consisted of 1-week conventional rehabilitation. OUTCOMES: The 5-week intervention promoted not only recovery from paralysis (8 points by the Fugl-Meyer Assessment), but also the ability to manipulate objects (13 points by the Action Research Arm test) and increased the subjective use of the affected upper limb during activities of daily living (2.88 points by the Motor Activity Log). Changes that exceeded the minimal clinically important difference occurred only in the RFE-under-cNMES period. CONCLUSIONS: The patient had improved outcomes. Further studies are required to determine the possibility of RFE-under-cNMES relieving motor paralysis in patients with PMIHP who do not recover rapidly.

Effect of Functional Electrical Stimulation in Convalescent Stroke Patients: A Multicenter, Randomized Controlled Trial.

BACKGROUND: We evaluated whether the Walkaide® device could effectively improve walking ability and lower extremity function in post-stroke patients with foot drop. Patients aged 20-85 years with an initial stroke within ≤6 months and a functional ambulation classification score of 3 or 4 were eligible. MATERIALS AND METHODS: Patients were randomly allocated to the functional electrical stimulation (FES) or control group at a 1:1 ratio. A 40 min training program using Walkaide was additionally performed by the FES group five times per week for 8 weeks. The control group received the 40 min training program without FES. RESULTS: A total of 203 patients were allocated to the FES (n = 102) or control (n = 101) groups. Patients who did not receive the intervention or whose data were unavailable were excluded. Finally, the primary outcome data of 184 patients (n = 92 in each group) were analyzed. The mean change in the maximum distance during the 6-MWT (primary outcome) was 68.37 ± 62.42 m and 57.50 ± 68.17 m in the FES and control groups (difference: 10.86 m; 95% confidence interval: -8.26 to 29.98, p = 0.26), respectively. CONCLUSIONS: In Japanese post-stroke patients with foot drop, FES did not significantly improve the 6 min walk distance during the convalescent phase. The trial was registered at UMIN000020604.

Acute effects of a single warm-water bath on serum adiponectin and leptin levels in healthy men: a pilot study.

To preliminarily assess the acute effects of a single warm-water bath (WWB) on serum adipokine activity, we measured serum adiponectin, leptin and other metabolic profiles before, immediately after and 30 minutes after WWB in seven healthy male volunteers (mean age, 39.7 ± 6.0 years; mean body mass index, 21.6 ± 1.8 kg/m(2)). The subjects were immersed in tap water at 41°C for 10 minutes. Two weeks later, the same subjects underwent a single WWB with a bath additive that included inorganic salts and carbon dioxide (WWB with ISCO(2)) by the same protocol as for the first WWB. Leptin levels significantly increased immediately after WWB with tap water and ISCO(2) (both P < 0.05), and remained significantly higher than those at baseline even 30 minutes after WWB with tap water (P < 0.05). Adiponectin levels showed a slight, but not significant, increase both immediately after and 30 minutes after WWB with tap water or ISCO(2). Some parameters, such as serum total cholesterol, red blood cell count, hemoglobin and hematocrit significantly increased immediately after WWB with tap water or ISCO(2) (all P < 0.05), but they all returned to the baseline levels 30 minutes after bathing under both conditions. The sublingual temperature rose significantly after 10 minutes of WWB with tap water (0.96 ± 0.16°C relative to baseline, P < 0.01) and after the same duration of WWB with ISCO(2) (1.24 ± 0.34°C relative to baseline, P < 0.01). These findings suggest that a single WWB at 41°C for 10 minutes may modulate leptin and adiponectin profiles in healthy men.