Non-invasive Brain Stimulation Techniques for the Improvement of Upper Limb Motor Function and Performance in Activities of Daily Living After Stroke: A Systematic Review and Network Meta-analysis.

OBJECTIVE: To compare the efficacy of non-invasive brain stimulation (NiBS) such as transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), theta-burst stimulation (TBS), and transcutaneous vagus nerve stimulation (taVNS) in upper limb stroke rehabilitation. DATA SOURCES: PubMed, Web of Science, and Cochrane databases were searched from January 2010 to June 2022. DATA SELECTION: Randomized controlled trials (RCTs) assessing the effects of "tDCS", "rTMS", "TBS", or "taVNS" on upper limb motor function and performance in activities of daily livings (ADLs) after stroke. DATA EXTRACTION: Data were extracted by 2 independent reviewers. Risk of bias was evaluated with the Cochrane Risk of Bias tool. DATA SYNTHESIS: 87 RCTs with 3750 participants were included. Pairwise meta-analysis showed that all NiBS except continuous TBS (cTBS) and cathodal tDCS were significantly more efficacious than sham stimulation for motor function (standardized mean difference [SMD] range 0.42-1.20), whereas taVNS, anodal tDCS, and both low and high frequency rTMS were significantly more efficacious than sham stimulation for ADLs (SMD range 0.54-0.99). NMA showed that taVNS was more effective than cTBS (SMD:1.00; 95% CI (0.02-2.02)), cathodal tDCS (SMD:1.07; 95% CI (0.21-1.92)), and Physical rehabilitation alone (SMD:1.46; 95% CI (0.59-2.33)) for improving motor function. P-score found that taVNS is best ranked treatment in improving motor function (SMD: 1.20; 95% CI (0.46-1.95)) and ADLs (SMD:1.20; 95% CI (0.45-1.94)) after stroke. After taVNS, excitatory stimulation protocols (intermittent TBS, anodal tDCS, and HF-rTMS) are most effective in improving motor function and ADLs after acute/sub-acute (SMD range 0.53-1.63) and chronic stroke (SMD range 0.39-1.16). CONCLUSIONS: Evidence suggests that excitatory stimulation protocols are the most promising intervention in improving upper limb motor function and performance in ADLs. taVNS appeared to be a promising intervention for stroke patients, but further large RCTs are required to confirm its relative superiority.

Design of a Sensor-Technology-Augmented Gait and Balance Monitoring System for Community-Dwelling Older Adults in Hong Kong: A Pilot Feasibility Study.

Routine assessments of gait and balance have been recognized as an effective approach for preventing falls by issuing early warnings and implementing appropriate interventions. However, current limited public healthcare resources cannot meet the demand for continuous monitoring of deteriorations in gait and balance. The objective of this study was to develop and evaluate the feasibility of a prototype surrogate system driven by sensor technology and multi-sourced heterogeneous data analytics, for gait and balance assessment and monitoring. The system was designed to analyze users' multi-mode data streams collected via inertial sensors and a depth camera while performing a 3-m timed up and go test, a five-times-sit-to-stand test, and a Romberg test, for predicting scores on clinical measurements by physiotherapists. Generalized regression of sensor data was conducted to build prediction models for gait and balance estimations. Demographic correlations with user acceptance behaviors were analyzed using ordinal logistic regression. Forty-four older adults (38 females) were recruited in this pilot study (mean age = 78.5 years, standard deviation [SD] = 6.2 years). The participants perceived that using the system for their gait and balance monitoring was a good idea (mean = 5.45, SD = 0.76) and easy (mean = 4.95, SD = 1.09), and that the system is useful in improving their health (mean = 5.32, SD = 0.83), is trustworthy (mean = 5.04, SD = 0.88), and has a good fit between task and technology (mean = 4.97, SD = 0.84). In general, the participants showed a positive intention to use the proposed system in their gait and balance management (mean = 5.22, SD = 1.10). Demographic correlations with user acceptance are discussed. This study provides preliminary evidence supporting the feasibility of using a sensor-technology-augmented system to manage the gait and balance of community-dwelling older adults. The intervention is validated as being acceptable, viable, and valuable.

Gait speed and spasticity are independently associated with estimated failure load in the distal tibia after stroke: an HR-pQCT study.

This HR-pQCT study was conducted to examine bone properties of the distal tibia post-stroke and to identify clinical outcomes that were associated with these properties at this site. It was found that spasticity and gait speed were independently associated with estimated failure load in individuals with chronic stroke. PURPOSE: (1) To examine the influence of stroke on distal tibia bone properties and (2) the association between these properties and clinical outcomes in people with chronic stroke. METHODS: Sixty-four people with stroke (age, 60.8 ± 7.7 years; time since stroke, 5.7 ± 3.9 years) and 64 controls (age: 59.4 ± 7.8 years) participated in this study. High-resolution peripheral quantitative computed tomography (HR-pQCT) was used to scan the bilateral distal tibia, and estimated failure load was calculated by automated finite element analysis. Echo intensity of the medial gastrocnemius muscle and blood flow of the popliteal artery were assessed with ultrasound. The 10-m walk test (10MWT), Fugl-Meyer Motor Assessment (FMA), and Composite Spasticity Scale (CSS) were also administered. RESULTS: The percent side-to-side difference (%SSD) in estimated failure load, cortical area, thickness, and volumetric bone mineral density (vBMD), and trabecular and total vBMD were significantly greater in the stroke group than their control counterparts (Cohen's d = 0.48-1.51). Isometric peak torque and echo intensity also showed significant within- and between-groups differences (p ≤ 0.01). Among HR-pQCT variables, the %SSD in estimated failure load was empirically chosen as one example of the strong discriminators between the stroke group and control group, after accounting for other relevant factors. The 10MWT and CSS subscale for ankle clonus remained significantly associated with the %SSD in estimated failure load after adjusting for other relevant factors (p ≤ 0.05). CONCLUSION: The paretic distal tibia showed more compromised vBMD, cortical area, cortical thickness, and estimated failure load than the non-paretic tibia. Gait speed and spasticity were independently associated with estimated failure load. As treatment programs focusing on these potentially modifiable stroke-related impairments are feasible to administer, future studies are needed to determine the efficacy of such intervention strategies for improving bone strength in individuals with chronic stroke.

Effectiveness of exergaming-based interventions for mobility and balance performance in older adults with Parkinson's disease: systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: exergaming-based interventions (EbIs) have been proposed to improve older adults' mobility and balance performance. However, the effectiveness of such interventions for older adults with Parkinson's disease (OAPD) remains unclear. METHODS: seven databases (Web of Science, Medline, Academic Search Premier, CINAHL Complete, PsycINFO, PsychARTICLE and PubMed) were searched up to 7 April 2022. We assessed mobility and balance performance between EbIs groups and control groups or traditional physical training interventions (TPTIs) groups by comparing the outcomes of the Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), gait velocity, stride length and Functional Gait Assessment (FGA). RESULTS: we scanned 1,190 articles and meta-analysed 19 trials (sample size = 781). In general, the results revealed statistical differences between EbIs groups and TPTIs groups in the TUG [mean difference (MD) = -1.030 s; 95% confidence interval (CI) = -2.029 to -0.031; P = 0.043; high quality of evidence], 6MWT (MD = 63.483 m; 95% CI = 9.542 to 117.425; P = 0.021; moderate quality of evidence), BBS (MD = 2.129; 95% CI = -1.293 to 2.965; P < 0.001; high quality of evidence) and FGA (MD = 2.099 95% CI = -0.306 to 3.893; P = 0.022; moderate quality of evidence). No significant difference was discovered between EbIs groups and TPTIs groups in enhancing gait velocity and stride length. CONCLUSIONS: EbIs are statistically better than TPTIs in improving OAPD's performance in TUG, 6MWT, BBS and FGA, whereas only the change between EbIs and TPTIs in 6MWT can reach the value of minimal clinically important difference. Further studies are needed to better assess the effectiveness of exergaming-based interventions.

Convergent Validity and Test-Retest Reliability of Multimodal Ultrasonography and Related Clinical Measures in People With Chronic Stroke.

OBJECTIVE: To assess the test-retest reliability of diagnostic ultrasonography measurements of the bilateral biceps brachii (BB), brachial artery, medial gastrocnemius (MG), and popliteal artery in survivors of stroke and their convergent validity with related clinical comparators. DESIGN: Cross-sectional study. SETTING: All procedures were conducted in a university laboratory. PARTICIPANTS: Sixty-five community dwelling adults (N=65; 26 women, 39 men) with an average age of 60.9±7.7 years and stroke duration of 5.7±3.9 years participated in this study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measures of muscle structure (ie, thickness, cross-sectional area, fascicle length, pennation angle), stiffness, and intramuscular blood perfusion were conducted using B-mode, elastography and color flow Doppler ultrasonography modes, respectively. Convergent validity was assessed by examining correlations between ultrasonography measures and assessments of related constructs (ie, dynamic stiffness, isometric peak torque, spasticity, and systemic vascular function using myotonometry, dynamometry, the Composite Spasticity Scale, and the Ankle-Brachial Index, respectively). A 2-way random-effects intraclass correlation coefficient (ICC) model (ICC2,3) was used to determine agreement between intersession measures among a smaller cohort of participants with stroke (n=20). RESULTS: ICC estimates ranged from moderate to excellent for muscle stiffness (paretic: ICC=0.74-0.89; nonparetic: ICC=0.66-0.88), structure (paretic: ICC=0.87-0.99; nonparetic: ICC=0.81-0.98), and blood perfusion measures (paretic: ICC=0.74-0.84; nonparetic: ICC=0.73-0.88). Weak to moderate associations were found between myotonometry and elastography measures of the bilateral BB (r=0.29-0.52, P≤.05) and MG muscles (r=0.31-0.69, P≤.05). The correlations between elastography measures and spasticity scores for the paretic upper (r=0.35-0.63, P≤.05) and lower limbs (r=0.25-0.37, P≤.05) were also weak to moderate. CONCLUSIONS: Elastography demonstrated mostly weak to moderate correlation with measures of stiffness using myotonometry as well as scores of paretic upper and lower limb spasticity. The results also indicate acceptable intersession reliability for muscle and vascular measures using several ultrasonography modalities among individuals with chronic stroke.

Translation and psychometric validation of the traditional Chinese version of patient-reported outcomes measurement information system Pediatric-25 Profile version 2.0 (PROMIS-25) in Chinese Children with Cancer in Hong Kong.

PURPOSE: To translate and cross-cultural validate the PROMIS Pediatric-25 Profile 2.0 (PROMIS-25) into traditional Chinese, and to investigate its psychometric properties in children with cancer in Hong Kong. METHODS: The Functional Assessment of Chronic Illness Therapy translation methodology was adopted in this study. Three panel members evaluated the semantic equivalence and content validity. The psychometric properties were tested with 103 children with cancer (10-18 years). Internal consistency and structural validity were examined by Cronbach's alpha and Rasch analysis. Convergent and divergent validity were assessed by correlating it with traditional Chinese pediatric quality of life inventory™ 4.0 domains (traditional Chinese PedsQL™ 4.0), traditional Chinese Health Questionnaire-9 (C-PHQ-9), and the numeric pain rating scale (NPRS). RESULTS: The semantic equivalence score and content validity index were both 100%. All domains indicated good internal consistency (α = 0.83-0.88) and unidimensionality (variance explained > 55.5% and 1st contrast eigenvalues < 2.0). All items showed good item fit (0.6-1.4). For convergent validity, the traditional Chinese PROMIS-25 domains demonstrated moderate-to-large correlations with traditional Chinese PedsQL™ 4.0 domains (r ≥ ± 0.69), C-PHQ-9 Item-4 and total score (r = 0.75-0.80), except NPRS (r = 0.44). For divergent validity, traditional Chinese PROMIS-25 had low correlations with traditional Chinese PedsQL™ 4.0 domains (r < ± 0.21), C-PHQ-9 item-4 (r = 0.3), and NPRS (r = - 0.12). The traditional Chinese PROMIS-25 fatigue domain was weakly correlated with NPRS (r = 0.39). CONCLUSION: The traditional Chinese PROMIS-25 is semantically and conceptually like the original PROMIS-25 with satisfactory internal consistency, structural validity, and construct validity.

Standing Balance Strategies and Dual-Task Interference Are Differentially Modulated Across Various Sensory Contexts and Cognitive Tests in Individuals With Chronic Stroke.

BACKGROUND AND PURPOSE: Mental tracking and verbal fluency tests have been linked to poor mobility and falls; however, no studies have examined the influence of imposing these tests on standing balance post-stroke. The purpose of this study was to investigate standing balance and cognitive performance across sensory conditions and cognitive tests post-stroke. METHODS: Ninety-two participants with chronic stroke stood on dual-force platforms while performing various sensory conditions (eyes open/fixed surface, eyes closed/fixed surface, eyes open/sway-referenced surface, and eyes closed/sway-referenced surface) and cognitive tests (no cognitive test, serial subtractions, and verbal fluency). Equilibrium scores were computed based on the anterior-posterior sway angle. The number of correct verbal responses was recorded. RESULTS: Performing serial subtractions during eyes closed/sway-referenced surface revealed the highest equilibrium score (64.0 ± 13.5), followed by the same sensory condition with added verbal fluency test (59.6 ± 15.1), followed by the single-task condition with no cognitive test (52.6 ± 20.9). The number of correct serial subtractions between seated (7.7 ± 3.7) and standing (7.2 ± 3.5) conditions was similar. A trend for more correct verbal fluency responses emerged when seated (8.1 ± 2.9) than the eyes open/sway-referenced surface condition (7.5 ± 2.8). Greater correct verbal fluency responses emerged when seated (8.6 ± 3.1) than the eyes closed/sway-referenced surface condition (7.8 ± 2.7). DISCUSSION AND CONCLUSIONS: Standing balance enhancement (higher equilibrium score/better balance) depends on the neuropsychological process targeted and the sensory input available post-stroke. Cognitive dual-task interference emerged for the verbal fluency test during the most attention demanding sensory condition. Cognitive tests that enhance standing balance should be considered in assessments and interventions to evaluate and improve dual-tasking post-stroke.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A321).

Muscle activity and vibration transmissibility during whole-body vibration in chronic stroke.

PURPOSE: This study aimed to investigate the influence of whole-body vibration (WBV) frequency, amplitude, and body posture on lower limb muscle activation among people with chronic stroke, and whether the EMG response to vibration stimulus differed between paretic and non-paretic side. The relationship between muscle activation and WBV transmission was also examined. METHOD: Thirty-two participants with chronic stroke performed three different exercises on the WBV platform with different vibration conditions (frequency: 20 Hz, 30 Hz, 40 Hz; amplitude: 0.8 mm, 1.5 mm), or without vibration. Muscle activity in bilateral vastus medialis (VM), medial hamstrings (MH), tibialis anterior (TA), and medial gastrocnemius (MG) was measured by surface electromyography. Acceleration at the platform and bilateral hips and knees was measured by tri-axial accelerometers. RESULTS: Significantly greater muscle activity was observed in the bilateral MG (P < 0.001), TA (P < 0.001), and MH (P < 0.001), but not VM, compared with the same exercises without WBV. WBV with higher amplitude or higher frequency led to greater augmentation of muscle activation (P < 0.05). Body posture significantly affected leg muscle activation (P < 0.001). WBV-induced muscle activation was largely similar between paretic and non-paretic sides, except the TA. Greater WBV-induced leg muscle activation was associated with lower WBV transmissibility measured at the more proximal joints (P < 0.05). CONCLUSION: Adding WBV to exercise significantly increased muscle activation in the MG, TA, and MH on both the paretic and non-paretic sides of chronic stroke survivors, and the increase was dependent on the WBV amplitude, frequency, and body posture.

Effects of adding whole-body vibration to routine day activity program on physical functioning in elderly with mild or moderate dementia: a randomized controlled trial.

OBJECTIVE: To evaluate the effects of whole-body vibration (WBV) added to a routine activity program on lower limb strength, balance, and mobility among community-dwelling individuals with mild or moderate dementia, compared with the routine program alone. METHODS: Fifty-four older adults (40 women; mean (SD) age: 79.8 (6.1) years) with mild or moderate dementia were recruited from two daycare centers. The participants were randomly allocated to undergo a routine day activity program combined with WBV training (WBV at 30 Hz, 2-mm peak-to-peak amplitude) or the routine program only without WBV for 9 weeks (18 sessions). The primary outcome was functional mobility, measured using the timed up-and-go test. The following secondary outcomes were evaluated: Berg Balance Scale, Tinetti balance assessment, time to complete 5 repetitions of sit-to-stand, Quality of Life in Alzheimer's disease questionnaire, and Activities-specific Balance Confidence scale. The attendance rate and incidence of adverse events were also recorded. RESULTS: The attendance rate for the training was high (86.0%). The incidence of adverse events was low, with only two of the 27 participants in the WBV group reporting mild knee pain. While significant improvement in timed up-and-go, Berg Balance Scale, and Tinetti balance score was found in both groups, none of the outcomes demonstrated a significant group by time interaction. CONCLUSIONS: WBV training is feasible and safe to use with people with mild or moderate dementia. However, it did not lead to further improvement in physical function and quality of life than the usual activity program provided at the daycare centers. Copyright © 2017 John Wiley & Sons, Ltd.

Relationship Between Nutritional Factors and Hip Bone Density in Individuals with Chronic Stroke.

The aim of this study was to investigate the relationship between dietary habits and hip bone health in community-dwelling individuals with chronic stroke. The usual dietary intake of 94 individuals with chronic stroke (30 women, mean age: 59.0 years) was assessed by a 3-day food record within a single week. Dual-energy X-ray absorptiometry was used to measure bone mineral density (BMD) at both hips. The results showed that low hip bone mass was found in 59 and 50 of the participants on the affected and unaffected side, respectively. The mean hip BMD was also significantly lower on the affected side than the unaffected side (P < 0.001). The intake of total fat, carbohydrates, calcium, magnesium, iron, zinc, fiber, folic acid, vitamin B1, B2, B3, B6, C, and K was significantly lower than the respective recommended daily intake values (P < 0.05). Multiple regression analyses revealed that after adjusting for the effects of age, sex, body mass index, post-stroke duration, side of paresis, motor impairment, physical activity level, walking endurance, total calories intake, and total number of medications, intake of protein, fiber, and magnesium remained significantly associated with hip T score on the affected side, accounting for 4.2, 4.4, and 3.2% of the variance, respectively. On the other hand, intake of protein and fiber was independently associated with hip T score on the unaffected side, explaining 2.7 and 5.2% of the variance, respectively. The results highlighted the potential relevance of diet modification in maintaining bone health post stroke, which would require further study.

Vitamin D and oxidation-induced DNA damage: is there a connection?

Oxidation-induced damage to DNA can cause mutations, phenotypic changes and apoptosis. Agents that oppose such damage offer potential therapies for disease prevention. Vitamin D administration reportedly lowered DNA damage in type 2 diabetic mice, and higher DNA damage was reported in mononuclear cells of severely asthmatic patients who were vitamin D deficient. We hypothesised that lower vitamin D status associates with higher oxidation-induced DNA damage. Vitamin D deficiency (plasma 25(OH)D < 50 nmol/l) is highly prevalent worldwide, and association with DNA damage has high potential importance and impact in regard to the future health of vitamin D deficient young adults. In this study, oxidation-induced DNA damage in peripheral lymphocytes of 121 young (18-26 years) adults was measured using the formamidopyrimidine DNA glycosylase (FPG)-assisted comet assay. Plasma 25(OH)D was measured by liquid chromatography with tandem mass spectrometry (LC-MS/MS). Correlational analysis was performed between 25(OH)D and DNA damage. Differences in DNA damage across tertiles of 25(OH)D were explored using analysis of variance. DNA damage in those with 25(OH)D <50 nmol and ≥50 nmol/l was compared using the unpaired t-test. Mean (SD) DNA damage (as %DNA in comet tail) and plasma 25(OH)D were, respectively, 18.58 (3.39)% and 44.7 (13.03) nmol/l. Most (82/121; 68%) of the subjects were deficient in vitamin D (25(OH)D <50nmol/l). No significant correlation was seen between 25(OH)D and DNA damage (r = -0.0824; P > 0.05). No significant difference was seen across 25(OH)D tertiles: mean (SD) %DNA in comet tail/25(OH)D nmol/l values in lowest, middle and highest tertiles were, respectively, 18.64 (3.30)/31.6 (4.4), 18.90 (3.98)/42.9 (3.5), 18.19 (2.84)/59.9 (8.5), nor across the binary divide: 18.73 (3.63)% in <50nmol/l group vs. 18.27 (2.84)% in the ≥50 nmol/l group. No association between vitamin D and oxidation-induced DNA damage was observed, but vitamin D deficiency was highly prevalent in the young adults studied, and we cannot rule out an ameliorative effect of correction of vitamin D deficiency on DNA damage.

Correlation between tibial measurements using peripheral quantitative computed tomography and hip areal bone density measurements in ambulatory chronic stroke patients.

OBJECTIVE: Peripheral quantitative computed tomography (pQCT) has been increasingly used in stroke research. The correlations between tibial bone measurements by pQCT and hip areal bone mineral density (aBMD) measurements by dual-energy x-ray absorptiometry (DXA) (gold standard for diagnosing osteoporosis) in chronic stroke patients were examined in this study. If the correlations were strong, there may be potential for further pursuit of clinical use of pQCT. METHODS: Seventy-four chronic stroke patients who are household ambulators (22 women, 52 men; ≥ 6 months after onset) underwent pQCT scanning of the tibial distal epiphysis (4% site) and diaphysis (66% site) and DXA hip scans on both sides. Pearson's correlation coefficients were used to investigate the correlations between the pQCT-derived variables and the DXA-derived total hip and femoral neck aBMD. RESULTS: All pQCT tibial variables, except the total area, were significantly associated with total hip and femoral neck aBMD. Cortical bone mineral content (66% site) was the only variable that yielded good-to-excellent correlations with total hip and femoral neck aBMD on both sides (r = 0.750-0.833). CONCLUSIONS: Based on the good correlations between tibial pQCT variables and hip aBMD, the clinical use of pQCT in assessing bone health in this population should be further pursued.

Correction: He et al. Impacts of Cigarette Smoke (CS) on Muscle Derangement in Rodents-A Systematic Review. Toxics 2022, 10, 262.

In the original publication [...].

Non-pharmacological and pharmacological treatments for bone health after stroke: Systematic review with meta-analysis.

BACKGROUND: Hemi-osteoporosis is a common secondary complication of stroke. No systematic reviews of pharmacological and non-pharmacological agents for post-stroke bone health have estimated the magnitude and precision of effect sizes to guide better clinical practice. OBJECTIVES: To examine the benefits and harms of pharmacological and non-pharmacological agents on bone health in post-stroke individuals. METHODS: Eight databases were searched (PubMed, Cochrane library, Scopus, CINAHL Complete, Embase, PEDro, Clinicaltrils.gov and ICTRP) up to June 2023. Any controlled studies that applied physical exercise, supplements, or medications and measured bone-related outcomes in people with stroke were included. PEDro and the GRADE approach were used to examine the methodological quality of included articles and quality of evidence for outcomes. Effect sizes were calculated as standardized mean differences (SMD) and risk ratio (RR). Review Manager 5.4 was used for data synthetization. RESULTS: Twenty-four articles from 21 trials involving 22,500 participants (3,827 in 11 non-pharmacological and 18,673 in 10 pharmacological trials) were included. Eight trials were included in the meta-analysis. The methodological quality of half of the included non-pharmacological studies was either poor or fair, whereas it was good to excellent in 8 of 10 pharmacological studies. Meta-analysis revealed a beneficial effect of exercise on the bone mineral density (BMD) of the paretic hip (SMD: 0.50, 95 % CI: 0.16; 0.85; low-quality evidence). The effects of anti-resorptive medications on the BMD of the paretic hip were mixed and thus inconclusive (low-quality evidence). High-quality evidence showed that the administration of antidepressants increased the risk of fracture (RR: 2.36, 95 % CI 1.64-3.39). CONCLUSION: Exercise under supervision may be beneficial for hip bone health in post-stroke individuals. The effect of anti-resorptive medications on hip BMD is uncertain. The adverse effects of antidepressants on fracture risk among post-stroke individuals warrant further attention. Further high-quality studies are required to better understand this issue. REGISTRATION: PROSPERO CRD42022359186.

Knee muscle strength and visual acuity are the most important modifiable predictors of falls in patients after hip fracture surgery: a prospective study.

Our purpose was to identify risk factors for falls among older adults who had recently undergone hip fracture surgery. The subjects in this study were 69 older adults (aged 65 years or more) who had sustained a hip fracture and were admitted to an orthopedic rehabilitation ward after surgery. Potential fall risk factors were assessed using the physiological profile assessment, timed-up-and-go test, berg balance test, and activities-specific balance confidence scale at discharge from the hospital. Each individual was followed for a period of 6 months to obtain information on the incidence of falls. Receiver operating characteristic curves were constructed to determine the optimal cutoff score for each potential risk factor identified. Multivariate logistic regression was then used to identify the significant predictors of falls and their odds ratios (ORs). During the 6-month follow-up period, 10 of the 69 patients experienced one or more falls. The results showed that fallers were older than nonfallers (p=0.009). Fallers also had poorer performance in the high-contrast visual acuity test (p=0.015) and lower knee flexor (p=0.021) and knee extensor (p=0.005) muscle strength values. Multivariate logistic regression analysis showed that high-contrast visual acuity (cutoff score Z=-2.280, OR=6.14, 95% CI 1.13-33.29, p=0.035) and knee extensor muscle strength (cutoff score Z=-1.835, OR=4.81, 95% CI 1.04-22.33, p=0.045) were predictors of falls. Poor visual acuity and knee muscle weakness are modifiable predictors of falls and should be the key target areas in fall-prevention programs for older adults with hip fractures.

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.

Changes in activity levels in the first month after stroke.

[Purpose] To quantify the activity levels of individuals in an acute stroke ward, and to determine if their activity levels change within the first month after stroke. [Methods] In this pilot study, participant activity was monitored prospectively over a single day from 8 a.m. to 5 p.m. on two separate occasions. Individuals with confirmed stroke > 18 years of age and less than 15 days post-stroke at the time of recruitment were eligible for inclusion in this study. Activity was recorded using an electronic device. The first day was scheduled within 15 days and the second at four weeks post-stroke. We looked at the following activity categories: number of transitions, and the times spent lying, sitting and in dynamic activity. [Results] Sixteen individuals were included in this study with a median age of 79.5 years (interquartile range 62.5 to 85). Fifty-six % of the participants had mild, 31% had moderate and 13% had severe stroke, according to the NIHSS score. There were no significant changes in number of transitions, or times spent in dynamic activity and lying and sitting. [Conclusion] Activity levels were low at an acute stroke ward and did not significantly change within the first month.

Effects of mechanical stimulation on mastectomy scars within 2 months of surgery: A single-center, single-blinded, randomized controlled trial.

BACKGROUND: One common complication after mastectomy is thickened scars at the surgical site that impair shoulder function. This study aimed to investigate the effects of mechanical stimulation on scar appearance, arm function, and quality of life of breast cancer survivors after mastectomy. METHODS: This was a single-center, single-blinded (assessor), randomized controlled trial with a 3-month follow-up. Women who had undergone mastectomy in the preceding 6 weeks for breast cancer were randomly allocated to an experimental group and a control group by permuted block randomization (block size=6). The experimental group received conventional treatment (mobilization and strengthening exercises) and mechanical stimulation applied to the mastectomy scar twice a week for 6 weeks (12 sessions). The control group received 12 sessions of conventional treatment only. Primary outcome measures included the Vancouver Scar scale (VSS) to assess scar quality. The secondary outcomes were spectrophotometry, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; shoulder range of motion; the Numeric Pain Rating scale; hand grip strength; and Functional Assessment of Chronic Illness Therapy-Breast Cancer (FACT-B). RESULTS: One hundred and eight participants were equally randomized to 2 groups. All follow-up assessments were completed in September 2018. Intention-to-treat analysis revealed a significant group × time interaction on the VSS (η² = 0.161, p < 0.001), DASH (η² = 0.060, p = 0.003), and FACT-B functional well-being scores (η² = 0.033, p = 0.034), indicating that the experimental group (n=54) showed greater improvement in these outcomes than the control group (n=54). Post-hoc analysis showed that the improvements in the VSS and DASH scores remained apparent at the 3-month follow-up. Other outcomes did not yield significant group × time interaction. No adverse effects were reported. CONCLUSION: The addition of mechanical stimulation to a conventional intervention program improved scar appearance, arm function, and functional well-being compared with conventional intervention alone.

Using ultrasound elastography to assess non-invasive, non-pharmacological interventions for musculoskeletal stiffness: a systematic review and meta-analysis.

PURPOSE: To evaluate the current evidence regarding the use of ultrasound elastography for assessing non-invasive, non-pharmacological interventions for eliciting changes in musculoskeletal stiffness. METHODS: A systematic search of MEDLINE, CINAHL, EMBASE, and Web of Science databases was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Information on measurement and intervention procedures was extracted. Bias was assessed using Cochrane Risk of Bias or Risk of Bias In Non-randomised Studies of Interventions (ROBINS-I) tools for studies with true or quasi-experimental designs, respectively. Analyses were conducted for adequately powered subgroups based on intervention type, measurement site, and population assessed. RESULTS: Twenty-one studies were included in the review. Overall risk of bias was low for true experimental studies and moderate for quasi-experimental studies. Subgroup analyses indicated a large overall effect for interventions involving manual physiotherapy and taping/splinting for reducing masseter muscle stiffness in patients with masticatory muscle disorders (g = 1.488, 95% CI = 0.320-2.655, p = 0.013). Analyses for other intervention types and patient groups were underpowered. CONCLUSION: Ultrasound elastography demonstrates clinical applicability for assessing non-invasive, non-pharmacological interventions for musculoskeletal stiffness. However, the comparative efficacy of these interventions for modulating tissue stiffness remains inconclusive.

Elastography demonstrates clinical applicability for assessing non-invasive, non-pharmacological interventions for musculoskeletal stiffnessInterventions involving manual physiotherapy and taping/bracing showed a large overall effect for reducing masseter muscle stiffnessThe comparative efficacy of other interventions remains inconclusive.

Effectiveness and cost of integrated cognitive and balance training for balance and falls in cerebellar ataxia: a blinded two-arm parallel group RCT.

Background: In patients with cerebellar ataxia (CA), dual-tasking deteriorates the performance of one or both tasks. Objective: Evaluate the effects of 4 weeks of cognitive-coupled intensive balance training (CIBT) on dual-task cost, dynamic balance, disease severity, number of falls, quality of life, cognition and cost among patients with CA. Methods: This RCT compared CIBT (Group 1) to single-task training (Group 2) among 32 patients with CA. The intervention included either dual-task (CIBT) or single-task training for 4 weeks followed by 6 months of unsupervised home exercises. Dual-task timed up-and-go test (D-TUG) assessed dual-task cost of the physical and cognitive tasks. Assessment time points included baseline 1 (Week 0:T1), baseline 2 (Week 6:T2), post-intervention (Week 10:T3), and follow-up (Week 34:T4). Results: Compared to single-task training CIBT improved the dual-task cost of physical task [MD -8.36 95% CI (-14.47 to -2.36, p < 0.01), dual-tasking ability [-6.93 (-13.16 to -0.70); p = 0.03] assessed using D-TUG, balance assessed using the scale for the assessment and rating of ataxia (SARAbal) [-2.03 (-4.04 to -0.19); p = 0.04], visual scores of the SOT (SOT-VIS) [-18.53 (-25.81 to -11.24, p ≤ 0.01] and maximal excursion [13.84 (4.65 to 23.03; p ≤ 0.01] of the Limits of Stability (LOS) in the forward direction and reaction time in both forward [-1.11 (-1.42 to -0.78); p < 0.01] and right [-0.18 (0.05 to 0.31); p < 0.01] directions following 4 weeks of training. CIBT did not have any additional benefits in reducing the number of falls, or improving disease severity, quality of life and cognition. The mean cost of intervention and healthcare costs for 7 months was HKD 33,380 for CIBT group and HKD 38,571 for single-task training group. Conclusion: We found some evidence to support the use of CIBT for improving the dual-tasking ability, dual-task cost of physical task and dynamic balance in CA. Future large fully-powered studies are needed to confirm this claim. Clinical trial registration: https://clinicaltrials.gov/study/NCT04648501, identifier [Ref: NCT04648501].