Rest-Activity Rhythm Differences in Acute Rehabilitation Between Poststroke Patients and Non-Brain Disease Controls: Comparative Study.

BACKGROUND: Circadian rhythm disruptions are a common concern for poststroke patients undergoing rehabilitation and might negatively impact their functional outcomes. OBJECTIVE: Our research aimed to uncover unique patterns and disruptions specific to poststroke rehabilitation patients and identify potential differences in specific rest-activity rhythm indicators when compared to inpatient controls with non-brain-related lesions, such as patients with spinal cord injuries. METHODS: We obtained a 7-day recording with a wearable actigraphy device from 25 poststroke patients (n=9, 36% women; median age 56, IQR 46-71) and 25 age- and gender-matched inpatient control participants (n=15, 60% women; median age 57, IQR 46.5-68.5). To assess circadian rhythm, we used a nonparametric method to calculate key rest-activity rhythm indicators-relative amplitude, interdaily stability, and intradaily variability. Relative amplitude, quantifying rest-activity rhythm amplitude while considering daily variations and unbalanced amplitudes, was calculated as the ratio of the difference between the most active 10 continuous hours and the least active 5 continuous hours to the sum of these 10 and 5 continuous hours. We also examined the clinical correlations between rest-activity rhythm indicators and delirium screening tools, such as the 4 A's Test and the Barthel Index, which assess delirium and activities of daily living. RESULTS: Patients who had a stroke had higher least active 5-hour values compared to the control group (median 4.29, IQR 2.88-6.49 vs median 1.84, IQR 0.67-4.34; P=.008). The most active 10-hour values showed no significant differences between the groups (stroke group: median 38.92, IQR 14.60-40.87; control group: median 31.18, IQR 18.02-46.84; P=.93). The stroke group presented a lower relative amplitude compared to the control group (median 0.74, IQR 0.57-0.85 vs median 0.88, IQR 0.71-0.96; P=.009). Further analysis revealed no significant differences in other rest-activity rhythm metrics between the two groups. Among the patients who had a stroke, a negative correlation was observed between the 4 A's Test scores and relative amplitude (ρ=-0.41; P=.045). Across all participants, positive correlations emerged between the Barthel Index scores and both interdaily stability (ρ=0.34; P=.02) and the most active 10-hour value (ρ=0.42; P=.002). CONCLUSIONS: This study highlights the relevance of circadian rhythm disruptions in poststroke rehabilitation and provides insights into potential diagnostic and prognostic implications for rest-activity rhythm indicators as digital biomarkers.

Utility of Ultrasound Elastography to Evaluate Poststroke Spasticity and Therapeutic Efficacy: A Narrative Review.

Poststroke spasticity (PSS) is a common complication that affects function and daily self-care. Conservative PSS treatments include traditional rehabilitation, botulinum toxin injection, and extracorporeal shock wave therapy. Currently, the Modified Ashworth Scale and Modified Tardieu Scale are widely used tools to clinically evaluate spasticity, but the best tool for PSS assessment remained controversial. Ultrasound elastography (UE), including shear wave and strain image as the emerging method to evaluate soft tissue elasticity, became popular in clinical applications. Spastic biceps and gastrocnemius muscles were reported to be significantly stiffer compared to nonparetic muscles or healthy control using shear wave or strain elastography. More studies investigated the utility, reliability, and validity of UE in patients with PSS, but the contemporary consensus for the utility of UE in the measurement and therapeutic follow-up of PSS remained lacking. Therefore, this narrative review aimed to appraise the literature on the shear wave and strain elastography on PSS and summarize the roles of UE in assessing the therapeutic efficacy of different PSS interventions.

Potential of thermoresponsive hydrogel as an alternative therapy for rat knee osteoarthritis.

Osteoarthritis is a degenerative condition that is highly prevalent and primarily affects the joints. The knee is the most commonly affected site, impacting the lives of over 300 million individuals worldwide. This study presents a potential solution to address the unmet need for a minimally invasive technique in the treatment of osteoarthritis: a biocompatible, injectable, and thermoresponsive hydrogel. In comparison to commercially available products such as lyophilized platelets, dextrose, and triamcinolone, the thermoresponsive hydrogel exhibits significantly superior performance in dynamic behaviors, including print area, stability, and step cycle, when tested on rats with knee osteoarthritis. However, it demonstrates similar treatment efficacy to these products in static behaviors, as observed through histopathological and immunohistochemical analysis. Therefore, the thermoresponsive hydrogel holds promise as an effective alternative therapy for osteoarthritis. Moreover, by blending the hydrogel with drugs, controlled and sustained release can be achieved, thereby facilitating the long-term management of osteoarthritis symptoms.

Diagnosing metatarsal chip fractures with ultrasound: faster and better.

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Real-Time Automated Segmentation of Median Nerve in Dynamic Ultrasonography Using Deep Learning.

OBJECTIVE: The morphological dynamics of the median nerve across the level extracted from dynamic ultrasonography are valuable for the diagnosis and evaluation of carpal tunnel syndrome (CTS), but the data extraction requires tremendous labor to manually segment the nerve across the image sequence. Our aim was to provide visually real-time, automated median nerve segmentation and subsequent data extraction in dynamic ultrasonography. METHODS: We proposed a deep-learning model modified from SOLOv2 and tailored for median nerve segmentation. Ensemble strategies combining several state-of-the-art models were also employed to examine whether the segmentation accuracy could be improved. Image data were acquired from nine normal participants and 59 patients with idiopathic CTS. DISCUSSION: Our model outperformed several state-of-the-art models with respect to inference speed, whereas the segmentation accuracy was on a par with that achieved by these models. When evaluated on a single 1080Ti GPU card, our model achieved an intersection over union score of 0.855 and Dice coefficient of 0.922 at 28.9 frames/s. The ensemble models slightly improved segmentation accuracy. CONCLUSION: Our model has great potential for use in the clinical setting, as the real-time, automated extraction of the morphological dynamics of the median nerve allows clinicians to diagnose and treat CTS as the images are acquired.

Blood-cerebrospinal fluid barrier opening by modified single pulse transcranial focused shockwave.

Transcranial focused shockwave (FSW) is a novel noninvasive brain stimulation that can open blood-brain barriers (BBB) and blood-cerebrospinal fluid barriers (BCSFB) with a single low-energy (energy flux density 0.03 mJ/mm2) pulse and low-dose microbubbles (2 × 106/kg). Similar to focused ultrasound, FSW deliver highly precise stimulation of discrete brain regions with adjustable focal lengths that essentially covers the whole brain. By opening the BCSFB, it allows for rapid widespread drug delivery to the whole brain by cerebrospinal fluid (CSF) circulation. Although no definite adverse effect or permeant injury was noted in our previous study, microscopic hemorrhage was infrequently observed. Safety concerns remain the major obstacle to further application of FSW in brain. To enhance its applicability, a modified single pulse FSW technique was established that present 100% opening rate but much less risk of adverse effect than previous methods. By moving the targeting area 2.5 mm more superficially on the left lateral ventricle as compared with the previous methods, the microscopic hemorrhage rate was reduced to zero. We systemically examine the safety profiles of the modified FSW-BCSFB opening regarding abnormal behavior and brain injury or hemorrhage 72 hr after 0, 1, and 10 pulses of FSW-treatment. Animal behavior, physiological monitor, and brain MRI were examined and recorded. Brain section histology was examined for hemorrhage, apoptosis, inflammation, oxidative stress related immunohistochemistry and biomarkers. The single pulse FSW group demonstrated no mortality or gross/microscopic hemorrhage (N = 30), and no observable changes in all examined outcomes, while 10 pulses of FSW was found to be associated with microscopic and temporary RBC extravasation (N = 6/30), and abnormal immunohistochemistry biomarkers which showed a trend of recovery at 72 hrs. The results suggest that single pulse low-energy FSW-BCSFB opening is effective, safe and poses minimal risk of injury to brain tissue (Sprague Dawley, SD rats).

Sonographic evaluations of the skeletal muscles in patients with Pompe disease.

BACKGROUND: Pompe disease usually has muscle weakness due to glycogen accumulation. Heckmatt scale is commonly used to grade the pertinent findings of ultrasound. Nonetheless, it is difficult to detect subtle changes of the muscle. Besides, no ultrasonographic parameter has been proposed to predict the motor functions of Pompe disease. Therefore, we aimed to find out an ultrasonographic parameter that can quantify the muscle involvement and correlate with the motor functions in Pompe disease. METHODS: Eighteen patients with Pompe disease were enrolled. The echo heterogeneity index (standard deviation divided by mean echogenicity values by ImageJ analysis) and shear modulus were recorded from rectus femoris, biceps femoris, tibialis anterior, medial gastrocnemius, biceps brachii and triceps brachii muscles. Motor functions, including manual muscle strength, 6-min walk and four-limb stair climb tests were assessed. Correlations between ultrasonographic parameters and Heckmatt scale and motor functions were analyzed. RESULTS: The echo heterogeneity index, but not the shear modulus, was negatively correlated with the Heckmatt scale rating in all muscles. The echo heterogeneity indices of tibialis anterior (r = 0.698, p = 0.008) and medial gastrocnemius (r = 0.615, p = 0.025) muscles showed positive correlations with the walking distance. Besides, the echo heterogeneity indices of four lower limb muscles were negatively correlated with the duration of stair climbing. CONCLUSION: The echo heterogeneity index but not the shear modulus can be used to quantitatively describe the muscle involvement in Pompe disease. In addition, lower echo heterogeneity indices of lower limb muscles are associated with worse motor functions in these patients.

Association of clinical factors to functional outcomes in patients with stroke with large-vessel occlusion after endovascular thrombectomy.

BACKGROUND/PURPOSE: Multiple clinical factors have been reported to be associated with functional outcomes in patients with stroke. However, little is known about prognostic predictors of functional independence in patients with stroke undergoing endovascular thrombectomy (EVT). Our study aimed to investigate the correlation between multiple prognostic variables (including EVT and rehabilitation-related parameters) and functional outcomes in patients post-EVT. METHODS: This retrospective cohort study recruited patients hospitalized between December 2018 and March 2022. Patients with stroke with large-vessel occlusion who underwent EVT were eligible for inclusion in the study. Prognostic factors, including premorbid characteristics, laboratory data, EVT- and rehabilitation-related parameters, functional activity level, balance ability, swallowing, and sphincter function, were collected. Logistic regression and generalized linear models were used to analyze their correlations with functional outcomes. RESULTS: A total of 148 patients were included. In the univariate logistic regression analysis, younger age, premorbid functional independence, higher hemoglobin (Hb) level, lower National Institute of Health Stroke Scale (NIHSS) score, absence of hemorrhagic transformation in 14 days, no nasogastric (NG) tube placement, earlier rehabilitation, frequent daily rehabilitation sessions, more out-of-bed rehabilitation, better ability of sitting up, better initial sitting balance, higher Barthel index (BI), absence of immobility, and neurological complications were associated with favorable outcomes at 3 months. In the stepwise regression model, the predictors of favorable function at 3 months included age, ability to sit up, and frequency of daily rehabilitation sessions; favorable outcomes at 6 months were associated with age, ability to sit up, and swallowing function. CONCLUSION: In patients with stroke post-EVT, better functional outcomes were associated with prognostic variables, including younger age, better ability to sit up, normal swallowing function, and frequent daily rehabilitation sessions.

Impaired median nerve mobility in patients with carpal tunnel syndrome: a systematic review and meta-analysis.

OBJECTIVES: This systematic review and meta-analysis investigated the mobility of the median nerve (MN) in carpal tunnel syndrome (CTS) patients compared to healthy people. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed and the electronic databases including PubMed, Scopus, EMBASE, and Cochrane Library were searched up to April 2022. All published observational studies comparing the excursion of MN between participants with and without CTS were included. The quality of research was assessed by the Newcastle-Ottawa Scale tool. The primary outcome was the excursion of the MN under dynamic examination, representing nerve mobility quantified by the standardized mean difference (SMD) for random effect meta-analysis. RESULTS: Fourteen studies were included in the qualitative review, and twelve entered the meta-analysis involving a total of 375 CTS patients and 296 healthy controls. The forest plot revealed that the mobility of the MN significantly decreased in the CTS group compared to the non-CTS control (SMD = -1.47, 95% CI: -1.91, -1.03, p < 0.001, heterogeneity 82%). In subgroup analysis, both transverse and longitudinal methods for nerve excursion showed less nerve mobility in CTS than in non-CTS. CONCLUSIONS: This meta-analysis showed that the patients with CTS exhibited less mobility of the MN than those without CTS, suggesting MN mobility as a potential CTS marker. KEY POINTS: • The patients with CTS revealed less mobility of the median nerve than those without CTS. • The mobility of the median nerve could be regarded as a potential CTS marker.

The Application of Ultrasound Guidance in Electrodiagnostic Studies - A Narrative Review.

Electrodiagnostic studies, including nerve conduction study and electromyography, were conducted based on surface anatomy in a conventional manner. However, the anatomical variations and difficulty in the identification of target nerves or muscles render the accuracy of electrodiagnostic studies questionable. In recent years, high-resolution ultrasound (US) has been used to scan both the peripheral nerves and musculoskeletal system. Furthermore, an increasing number of clinicians have incorporated US into electrodiagnostic studies to achieve accurate sampling and prevent potential unwanted tissue injuries. In this review article, we present summarized information about the utility of US in assisting electrodiagnostic studies.

Deep Learning for Detecting Supraspinatus Calcific Tendinopathy on Ultrasound Images.

Background: The aim of the study was to evaluate the feasibility of convolutional neural network (CNN)-based deep learning (DL) algorithms to dichotomize shoulder ultrasound (US) images with or without supraspinatus calcific tendinopathy (SSCT). Methods: This was a retrospective study pertaining to US examinations that had been performed by 18 physiatrists with 3-20 years of experience. 133,619 US images from 7836 consecutive patients who had undergone shoulder US examinations between January 2017 and June 2019 were collected. Only images with longitudinal or transverse views of supraspinatus tendons (SSTs) were included. During the labeling process, two physiatrists with 6-and 10-year experience in musculoskeletal US independently classified the images as with or without SSCT. DenseNet-121, a pre-trained model in CNN, was used to develop a computer-aided system to identify US images of SSTs with and without calcifications. Testing accuracy, sensitivity, and specificity calculated from the confusion matrix was used to evaluate the models. Results: A total of 2462 images were used for developing the DL algorithm. The longitudinal-transverse model developed with a CNN-based DL algorithm was better for the diagnosis of SSCT when compared with the longitudinal and transverse models (accuracy: 91.32%, sensitivity: 87.89%, and specificity: 94.74%). Conclusion: The developed DL model as a computer-aided system can assist physicians in diagnosing SSCT during the US examination.

Ultrasound elastography for the evaluation of plantar fasciitis: A systematic review and meta-analysis.

PURPOSE: This meta-analysis aimed to investigate the utility of ultrasound (US) elastography in the assessment of plantar fasciitis (PF). METHODS: We searched PubMed, Embase, and Scopus and systemically reviewed clinical studies that used US elastography for imaging PF. The primary outcome was the comparison of plantar fascia stiffness between healthy controls and patients with PF, quantified using the weighted mean difference (WMD) and standardized mean difference (SMD). RESULTS: Eleven studies were included in the final systematic review and meta-analysis. In six studies that employed shear wave elastography, patients with PF had a lower shear wave velocity, with a WMD of -1.772 m/s (95 % confidence interval [CI], -2.663 to -0.880) and an SMD of -1.239 m/s (95 % CI, -1.876 to -0.603), compared to those with asymptomatic heels. One study using the strain ratio showed that the WMD and SMD of patients with diseased heels vs healthy controls were -0.400 (95 % CI, -0.850 to 0.050) and -0.442 (95 % CI, -0.946 to 0.062), respectively. In six articles that use the color histogram of strain elastography, less stiffness was consistently reported in the diseased plantar fascia compared with healthy controls. CONCLUSION: This meta-analysis showed that the plantar fasciae were less stiff in the PF group than in asymptomatic subjects. The diagnostic performance of US elastography (over B-mode) warrants further investigation.

Ultrasound imaging and treatment in a rare case with bilateral supinator syndrome.

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Novel Motor-Sparing Ultrasound-Guided Neural Injection in Severe Carpal Tunnel Syndrome: A Comparison of Four Injectates.

Nerve hydrodissection uses fluid injection under pressure to selectively separate nerves from areas of suspected entrapment; this procedure is increasingly viewed as potentially useful in treating carpal tunnel syndrome (CTS). The usage of normal saline (NS), 5% dextrose water (D5W), platelet-rich plasma (PRP), and hyaluronic acid (HA) as primary injectates for hydrodissection without an anesthetic can limit anesthetic-related toxicity and preserve the motor functions of the median nerve. Here, we describe a novel motor-sparing neural injection and compare the effect of these four injectates for severe CTS. We retrospectively reviewed the outcomes of 61 severe CTS cases after a single neural injection with NS, D5W, PRP, or HA. Outcomes were evaluated on the 1st and 6th months postinjection, including the Boston Carpal Tunnel Questionnaire (BCTQ) scores and the nerve cross-sectional area (CSA). The results revealed that PRP, D5W, and HA were more efficient than NS at all measured time points (p < 0.05), except for CSA at the 1st month between the NS and D5W groups. Single-injections of PRP and D5W seemed more effective than that of HA within 6 months postinjection for symptom and functional improvement (6th-month BCTQ-symptom, D5W vs. HA, p = 0.047; 1st-month BCTQ-symptom, PRP vs. HA, p = 0.018; 1st- and 6th-month BCTQ-function, D5W vs. HA, p = 0.002 and 0.016, respectively; 1st-month BCTQ-function, PRP vs. HA, p < 0.001). For reducing CSA, PRP and HA seemed more effective than D5W (HA > PRP > D5W on the 1st month and HA vs. D5W, p = 0.001; PRP > HA > D5W on the 6th month and PRP vs. D5W, p = 0.012).

Facilitating drug delivery in the central nervous system by opening the blood-cerebrospinal fluid barrier with a single low energy shockwave pulse.

BACKGROUND: The blood-cerebrospinal fluid (CSF) barrier (BCSFB) is critically important to the pathophysiology of the central nervous system (CNS). However, this barrier prevents the safe transmission of beneficial drugs from the blood to the CSF and thus the spinal cord and brain, limiting their effectiveness in treating a variety of CNS diseases. METHODS: This study demonstrates a method on SD rats for reversible and site-specific opening of the BCSFB via a noninvasive, low-energy focused shockwave (FSW) pulse (energy flux density 0.03 mJ/mm2) with SonoVue microbubbles (2 × 106 MBs/kg), posing a low risk of injury. RESULTS: By opening the BCSFB, the concentrations of certain CNS-impermeable indicators (70 kDa Evans blue and 500 kDa FITC-dextran) and drugs (penicillin G, doxorubicin, and bevacizumab) could be significantly elevated in the CSF around both the brain and the spinal cord. Moreover, glioblastoma model rats treated by doxorubicin with this FSW-induced BCSFB (FSW-BCSFB) opening technique also survived significantly longer than untreated controls. CONCLUSION: This is the first study to demonstrate and validate a method for noninvasively and selectively opening the BCSFB to enhance drug delivery into CSF circulation. Potential applications may include treatments for neurodegenerative diseases, CNS infections, brain tumors, and leptomeningeal carcinomatosis.