Effects of protein-enriched nutritional support on skeletal muscle mass and rehabilitative outcomes in brain tumor patients: a randomized controlled trial.

Patients with brain tumors require extensive and prolonged rehabilitation efforts as they suffer from lesion-induced motor weakness as well as treatment-related side effects, often leading to a significant decline in function. Protein supplements have shown positive effects on promoting muscle strength and physical performance in various tumor etiologies. However, reports on their effects specifically in brain tumor patients remain scarce. This study aims to investigate the feasibility and efficacy of protein supplements in enhancing rehabilitative outcomes via muscle strengthening and functional gain in brain tumor patients with neurological demise. Sixty brain tumor patients were randomly assigned to either a protein supplement or a control group, receiving either protein supplements or a placebo for 6 weeks, in conjunction with conventional rehabilitation therapy. Assessments before and after the intervention included laboratory tests, anthropometric measures using bioimpedance analysis, and functional assessments, which included the MMSE, the modified Barthel Index, the Beck Depression Inventory, the Brief Fatigue Inventory, the Timed Up and Go test, the 6-min walk test, the isokinetic quadriceps muscle strength test, and the handgrip power. After the intervention, the levels of serum hemoglobin, protein, albumin, and C-reactive protein were improved in both groups, however, the change was significant only in the protein group. The muscle strength was enhanced in both groups, however, the significant increase in pinch grasp power was only noted in the protein group (P < 0.05). The distance on 6MWT was also significantly extended at follow-up in the protein group (P < 0.01). In the subgroup analysis according to nutritional status, the moderate malnutrition group showed greater augmentation of muscle mass than those with adequate nutrition (P < 0.05). Interestingly, the amelioration of malnutrition was observed only the in protein group. This study using protein supplements to promote the rehabilitative potential of brain tumor patients revealed a significant effect on improving hemodynamic nutritional indices, muscle power reimbursement, and functional improvement, especially in malnourished patients. The safety and feasibility of protein supplements in brain tumor patients were affirmative in this study. Further studies with more patients may help confirm the secondary functional gain resulting from increased muscle power.Trial registration: This study was retrospectively registered in the Clinical Research Information Service, CRIS no. KCT0009113 on Jan 12, 2024.

Contrast-enhanced ultrasonography as an adjunctive method to ICG lymphography for functional lymphaticovenous anastomosis.

BACKGROUND AND OBJECTIVES: Indocyanine green (ICG) lymphography is the reference standard for evaluating lymphedema stage and identifying lymphatic vessels. However, the penetration depth was limited to 1-2 cm from the skin surface. This prospective study compares clinical outcomes following lymphaticovenous anastomoses (LVA) in patients with upper and lower limb lymphedema using contrast-enhanced ultrasonography (CEUS) with ICG as a preoperative imaging modality. METHODS: Under general anesthesia, Sonazoid® was injected subcutaneously to visualize functional lymphatic channels via CEUS. We analyzed the changes in limb circumference and inter-limb ratio (ILR) using bioimpedance to measure electrical resistance between the CEUS plus ICG group and the ICG-only group to see the effect of CEUS-assisted LVA. RESULTS: No significant demographic differences existed between the two groups (CEUS plus ICG group vs. ICG-only group). The ILR decrease of the Z1 value measured using bioimpedance was statistically significant (p = 0.042 for the upper limb, p = 0.002 for the lower limb)- CONCLUSIONS: CEUS allowed us to identify deep-lying, functional, and large lymphatic channels. In conclusion, the combination of CEUS and ICG for identifying lymphatic channels has the potential to lead to a more functional lymphovenous anastomosis.

Development and Validation of a Normal Tissue Complication Probability Model for Lymphedema After Radiation Therapy in Breast Cancer.

PURPOSE: To develop and test a multivariable normal tissue complication probability (NTCP) model predicting lymphedema in patients with breast cancer receiving radiation therapy. METHODS AND MATERIALS: We retrospectively reviewed 1345 patients with breast cancer who received radiation therapy from 2 independent institutions. The patients were divided into a training cohort (institution A, n = 368, all treated with 3-dimensional conformal external beam radiation therapy [RT] with 2 Gy/fraction) and an external validation cohort (institution B, n = 977, treated either with 3-dimensional conformal external beam RT or with volumetric modulated RT and either with 1.8-2.0 Gy/fraction or with 2.67 Gy/fraction). Axillary-lateral thoracic vessel juncture (ALTJ) was delineated. The multivariable model was generated using dosimetric and clinical parameters. The performance of the model was comprehensively validated internally and externally. RESULTS: During a median follow-up of 78.7 months for the entire cohort, 97 patients (7.2%) developed lymphedema. The multivariable model that took into account the number of lymph nodes dissected, as well as the volume of the ALTJ receiving a dose ≥35 Gy equivalent doses in 2-Gy fractions (ALTJ V35), showed good agreement between predicted and observed results for both internal and external validation (Hosmer-Lemeshow P value > .05). The area under the receiver operating characteristic curve (AUC) and negative log-likelihood values for the multivariable NTCP model were 0.89 and 0.19 in internal validation and 0.83 and 0.19 in external validation. In addition, the multivariable model performance was acceptable for hypofractionated regimens (AUC 0.70) and volumetric modulated arc therapy (AUC 0.69). The number of lymph nodes dissected and ALTJ V35 were found to be the most important factors influencing lymphedema after radiation therapy. CONCLUSIONS: We first developed and validated the multivariable NTCP model for the lymphedema incidence in patients with breast cancer after radiation therapy. The multivariable NTCP model showed excellent performance and robustness in predicting lymphedema in both internal and completely independent external validations. The multivariable model for lymphedema prediction was robust and reliable for different treatment modalities and fractionation regimens.

Association between Immediate Breast Reconstruction and the Development of Breast Cancer-Related Lymphedema.

BACKGROUND: With the increasing number of patients undergoing immediate breast reconstruction after mastectomy, the impact of immediate breast reconstruction on the risk of breast cancer-related lymphedema has become an emerging area of interest. This study aimed to identify the association between immediate breast reconstruction and postoperative lymphedema. METHODS: A retrospective cohort study was conducted from 2006 to 2016 with 5900 consecutive patients who underwent mastectomy for primary breast cancer with or without immediate breast reconstruction. After excluding patients with synchronous contralateral breast cancer, lymphedema before mastectomy, history of procedures performed in the axillary region, and follow-up data of less than 1 year, the cumulative incidence of lymphedema after immediate breast reconstruction and after no reconstruction was calculated and compared using multivariate Cox regression analysis. RESULTS: Overall, 5497 patients (mean age, 51.7 years) were included, and 630 developed lymphedema. The 5-year cumulative incidence rate of lymphedema was significantly reduced in patients who underwent immediate breast reconstruction versus control patients (9.6% versus 12.2%; P = 0.02). In the multivariate analysis, immediate breast reconstruction status (hazard ratio, 0.75; 95% confidence interval, 0.56 to 0.99; P = 0.042) was an independent predictor for lymphedema. Similar significant associations were observed in the subgroup analyses of patients with a body mass index less than 30 kg/m2 (P = 0.024), in those with fewer than 10 dissected lymph nodes (P = 0.042), or in those with adjuvant radiotherapy (P = 0.048). CONCLUSIONS: Immediate breast reconstruction was associated with a reduced risk of lymphedema. These results may be used for predicting the development of lymphedema following breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Risk factors for lower extremity lymphedema after surgery in cervical and endometrial cancer.

OBJECTIVE: Lower extremity lymphedema (LEL) is a well-known adverse effect related to cervical and endometrial cancer (CEC); however, very few studies have elucidated the clinicopathologic risk factors related to LEL. We investigated the incidence and risk factors in patients who received primary surgery and/or adjuvant radiotherapy (RT) or chemotherapy for CEC. METHODS: We retrospectively reviewed 2,565 patients who underwent primary surgery following CEC diagnosis between January 2007 and December 2020. LEL diagnosis was based on objective and subjective assessments by experts. We identified important predictors of LEL to construct a nomogram predicting individual risks of LEL. For internal validation of the nomogram, the original data were separated using the split-sample method in a 7:3 ratio of training data and test data. RESULTS: Overall, 858 patients (33.5%) received RT, 586 received external beam RT (EBRT), and 630 received intracavitary RT. During follow-up period, LEL developed in 331 patients, with an overall cumulative 5-year incidence of 13.3%. In multivariate analysis, age at primary treatment, use of docetaxel-based chemotherapy, type of hysterectomy, type of surgical pelvic lymph node (LN) assessment, number of dissected pelvic and para-aortic LNs, and EBRT field were the independent predictors of LEL. We subsequently developed the nomogram showing excellent predictive power for LEL. CONCLUSION: LEL is associated with various treatment modalities, and their interactions may increase the possibility of occurrences. De-escalation strategies for treatment modalities should be considered to reduce LEL in patients with CEC.

Feasibility of 24-h urine creatinine clearance as a renal function monitoring tool in spinal cord injury patients.

OBJECTIVE: Renal dysfunction is a major cause of morbidity in patients with spinal cord injury (SCI). A 24-h urine creatinine (Cr) clearance (24-h urine CCr) is cost-effective and easy to implement compared to renal scintigraphy in the evaluation of renal function. This study aimed to verify the feasibility of 24-h urine CCr in the SCI population by assessing the correlation with effective renal plasma flow (ERPF) on renal scintigraphy. METHODS: Data from 245 SCI patients (189 males, mean age: 50.2 years) were used in this retrospective review. Clinical characteristics, 24-h urine CCr, serum Cr, comorbidities, and body composition analyses were assessed for correlation with laboratory parameters including renal scintigraphy. Strong predictors of ERPF were determined by multivariate linear regression analysis. Areas under receiver-operating characteristic curves were calculated to evaluate the discriminating power of 24-h urine CCr to predict ERPF <250 ml/min. RESULTS: Spinal cord injury patients showed tubular dysfunction despite normal serum Cr and 24-h urine CCr. There was a significant correlation between 24-h urine CCr and ERPF, and 24-h urine CCr was one of the strongest predictors for ERPF (area under the curve 0.72, 95% CI 0.64-0.80, p < 0.000) among other parameters such as age, appendicular lean mass index, and body mass index. 24-h urine CCr was an independent predictor of ERPF in subacute (R2 = 0.497, p < 0.001) and chronic SCI patients (R2 = 0.664, p < 0.0001). The optimized 24-h urine CCr cut-off was 139.4 ml/min/1.72 m2 for predicting decreased ERPF <250 ml/min (sensitivity 67.6% and specificity 64.0%). CONCLUSION: 24-h urine CCr is a sensitive indicator for renal function deterioration of SCI patients. Further longitudinal studies with larger numbers of SCI patients are needed to confirm the feasibility of 24-h urine CCr for monitoring this population.

Impact of Rehabilitation Nutrition and Healthy Weight Maintenance in Motor-Complete Tetraplegia Patients.

Cachexia and low muscle mass in motor-complete tetraplegia are associated with poor outcomes. This study aimed to document anthropometric, body composition, and nutritional indices in patients and to assess the effect of a comprehensive rehabilitation nutrition program in cachexia and low muscle mass. For 34 motor-complete tetraplegia in the subacute phase, a comprehensive rehabilitation nutrition program was provided for 8 to 9 weeks. Risk of malnutrition, anthropometric and body composition indices, as well as laboratory tests were assessed upon admission and at discharge. A body mass index of less than 20.2 kg/m2 was used as the cut-off value for obesity. Upon admission, 73.5% of patients were classified as obese, half were at risk of malnutrition, and 29.4% were compatible with cachexia. Compared to the premorbid state, the non-obese group showed greater weight reduction (p < 0.01) and higher prevalence of low muscle mass (p = 0.004) than the obese group. Disease duration was different between groups (p < 0.01). After rehabilitation, malnutrition risk, protein levels, and hemodynamic results improved in both groups (p < 0.05). A significant time × group interaction was observed for muscle mass, skeletal muscle mass, and appendicular lean mass index (p < 0.05). Muscle mass was maintained while fat components increased in both groups. Functional improvement was negatively correlated with an increase in fat components (p < 0.05). A personalized rehabilitation nutrition intervention improved the nutritional status, body composition, and functional outcomes in motor-complete tetraplegia. The increase in muscle mass was associated with functional gain; healthy weight gain or maintenance may improve the level of independence. Further studies to endorse this beneficial evidence of rehabilitation nutrition in the maintenance of muscle component are needed.

Low-frequency repetitive magnetic stimulation suppresses neuroblastoma progression by downregulating the Wnt/ß-catenin signaling pathway.

Repetitive magnetic stimulation (rMS) has been suggested as a non-invasive treatment for various neurological or psychiatric diseases. Contrary to the application previously used, the purpose of the present study was to elucidate whether low-frequency rMS could suppress tumor progression in in vitro and in vivo neuroblastoma models, and to explore the underlying mechanisms. The results demonstrated that low-frequency rMS treatment significantly suppressed cell proliferation and tumor progression in the models. Moreover, low-frequency rMS treatment downregulated the Wnt/ß-catenin signaling pathway and induced apoptosis. The Wnt/ß-catenin signaling pathway activator, Wnt agonist, was found to counteract the effect of low-frequency rMS treatment, while the Wnt/ß-catenin signaling pathway inhibitor, Wnt antagonist, exhibited a tumor suppression effect, similar to the effect of low-frequency rMS treatment. Taken together, our data demonstrated that low-frequency rMS treatment suppressed neuroblastoma progression by downregulating the Wnt/ß-catenin signaling pathway, suggesting that low-frequency rMS treatment may be a potential therapeutic strategy for the tumor suppression.

Establishment of a qualified integrated care system after total knee arthroplasty as a role of regional rheumatoid and degenerative arthritis centers.

BACKGROUND: The geriatric population and advanced knee osteoarthritis are rapidly increasing in Korea, and the socioeconomic burden of total knee arthroplasty (TKA) is increasing. This study aimed to analyze the demographic, clinical and socioeconomic characteristics of patients who underwent TKA and to differentiate the factors affecting participation in inpatient-intensive rehabilitation programs after TKA in the Jeju regional rheumatoid and degenerative arthritis center established by the government. METHODS: This retrospective cohort study included 845 patients (735 females; 72.0 ± 5.8 years) diagnosed with primary osteoarthritis (OA) of the knee who underwent elective unilateral primary TKA between January 2013 and June 2016. Demographic, clinical, and socioeconomic characteristics, including age, body mass index, obesity, length of stay, OA severity, underlying disease, education level, occupation, and location of residence were reviewed. Patients were allocated to the TKA-only group (home discharge) and to the TKA + rehab group (participation in post-TKA rehabilitation). The variables were analyzed and compared before and after the establishment of the center and according to participation in intensive rehabilitation. RESULTS: Patients who underwent TKA were mostly female, in the 60 s, and had a high prevalence of comorbidities and obesity. After the rehabilitation center's establishment, the intensive post-TKA participation increased profoundly from 3% to 59.2%. Participants after the center establishment had lower mean BMI and a higher proportion of K-L grade 4 compared to those before the center establishment. The location of residence was the only factor differentiating the participation in the intensive rehabilitation. CONCLUSION: The regional rheumatoid and degenerative arthritis center was appropriate to satisfy the high unmet need for participating in the intensive rehabilitation after TKA and to execute the qualified integrated post-TKA care system. Policy support should ensure the early rehabilitation and a qualified integrated care system and prepare for the increased burden of revision. Future longitudinal studies should be conducted to assess the long-term effect of the integrated post-TKA rehabilitation program on functional outcomes and patient survivorship free from revision.

Comparison of Clinical Symptoms and Neurophysiological Findings in Patients With Chemotherapy Induced Peripheral Neuropathy.

Introduction: Taxanes are associated with a distal sensory neuropathy, significantly affecting cancer survivor quality of life. However, chemotherapy-induced peripheral neuropathy (CIPN) assessments are primarily based on clinical symptoms rather than objective neurophysiologic findings. Therefore, we investigated neurophysiologic changes in symptomatic subjects, comparing them with symptom severity. Materials and Methods: Medical charts of 111 subjects who were referred for CIPN diagnosis after chemotherapy for breast or ovarian cancer between May 1, 2016, and December 31, 2019, were retrospectively reviewed. Demographics, anthropometric parameters, and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale data were collected. The nerve conduction study (NCS) results, including sensory nerve action potentials recorded from sural nerves, were analyzed relative to clinical symptoms. To optimize follow-up (FU) NCS diagnostic sensitivity, relative references of FU sural amplitude reductions to >30% and an absolute reference <10 µV were used. Results: Eighty-eight female patients met the criteria, and 20 underwent FU NCS. Baseline and FU sural amplitudes showed significant positive correlation with respective LANSS scores (p < 0.01). FU sural amplitude was significantly lower than the initial result (p < 0.05). The FU LANSS score was not different from the initial score. Initial NCS sensitivity and specificity for clinically suspected CIPN diagnoses with LANSS were 69.7 and 47.3%, respectively. All 20 subjects with FU evaluation were clinically compatible with CIPN (LANSS >12) at initial and FU assessments. Among them, only six (30.0%) had abnormal sural amplitudes (<10µV for ≤50 s, <3 µV for 60 s, <1 µV for 70 s) in the initial NCS. In the FU NCS, sural amplitude became abnormal in five additional subjects. Between the initial and FU NCS, sural amplitude was reduced by > 30% in eight subjects (40.0%). NCS sensitivity increased to 65.0% when including either abnormal sural amplitudes or a > 30% reduction in sural amplitude in FU studies. Conclusions: Although clinical symptoms and NCS results were positively correlated, a single NCS point had limited value for suspected CIPN electrophysiological diagnoses. Serial NCS during chemotherapy might help assess the degree of chemotherapy-induced nerve damage, attain evidence of CIPN prior to symptom aggravation, and monitor the progression of CIPN. Further study is needed to find specific relative references for variable patient factors to increase the sensitivity of electrophysiological studies of clinically suspected CIPN.

The Association Between the Number of Retrieved Pelvic Lymph Nodes and Ipsilateral Lower Limb Lymphedema in Patients With Gynecologic Cancer.

PURPOSE: While the risk of lower limb lymphedema (LLE) after radical surgery for gynecologic malignancies is multifactorial, the limited assessment of lymph nodes (LNs), such as sentinel LN biopsy, has been incorporated into a standard procedure. We assessed the relationship between the number of LNs retrieved from the hemipelvis and the incidence of ipsilateral LLE (iLLE). METHODS: This retrospective study included 103 women with gynecologic cancer who had LNs removed with minimally invasive surgery between January 2014 and December 2018. For early detection of LLE, the patients were followed up by a lymphedema specialist who complied with the International Society of Lymphedema criteria. Potential risk factors for LLE were collected, and the risk factors were further investigated according to the number of LNs removed in a side-specific manner. RESULTS: LLE was diagnosed in 32 (31.1%) patients, and most of them were diagnosed with unilateral (n = 22) LLE rather than bilateral (n = 10). The number of pelvic LNs removed (p = 0.018), no lymphatic mapping (p = 0.034), and radiation (p = 0.020) were associated with the development of one or both LLEs. A side-specific analysis revealed that the incidence of iLLE increased significantly when four or more LNs were removed from the hemipelvis compared with three or fewer LNs (22.9% vs. 8.3%, p = 0.048). CONCLUSIONS: The number of pelvic LNs retrieved was associated with the incidence of LLE in patients with early gynecologic cancer. We identified the cutoff number per hemipelvis through side-specific analysis that could minimize the risk of iLLE. Further studies are needed to validate our results.

Risk of Lymphedema Following Contemporary Treatment for Breast Cancer: An Analysis of 7617 Consecutive Patients From a Multidisciplinary Perspective.

OBJECTIVE: The aim of this study was to identify the comprehensive risk factors for lymphedema, thereby enabling a more informed multidisciplinary treatment decision-making. SUMMARY BACKGROUND DATA: Lymphedema is a serious long-term complication in breast cancer patients post-surgery; however, the influence of multimodal therapy on its occurrence remains unclear. METHODS: We retrospectively collected treatment-related data from 5549 breast cancer patients who underwent surgery between 2007 and 2015 at our institution. Individual radiotherapy plans were reviewed for regional nodal irradiation (RNI) field design and fractionation type. We identified lymphedema risk factors and used them to construct nomograms to predict individual risk of lymphedema. Nomograms were validated internally using 100 bootstrap samples and externally using 2 separate datasets of 1877 Asian and 191 Western patients. RESULTS: Six hundred thirty-nine patients developed lymphedema during a median follow-up of 60 months. The 3-year lymphedema incidence was 10.5%; this rate increased with larger irradiation volumes (no RNI vs RNI excluding axilla I-II vs RNI including axilla I-II: 5.7% vs 16.8% vs 24.1%) and when using conventional fractionation instead of hypofractionation (13.5% vs 6.8%). On multivariate analysis, higher body mass index, larger number of dissected nodes, taxane-based regimen, total mastectomy, larger irradiation field, and conventional fractionation were strongly associated with lymphedema (all P < 0.001). Nomograms constructed based on these variables showed good calibration and discrimination internally (concordance index: 0.774) and externally (0.832 for Asian and 0.820 for Western patients). CONCLUSIONS: Trimodality breast cancer treatment factors interact to promote lymphedema. Lymphedema risk can be decreased by deintensifying node dissection, chemotherapy regimen, and field and dose of radiotherapy. Deescalation strategies on a multidisciplinary basis might minimize lymphedema risk.

Associations between hand function and electrophysiological measurements in hand osteoarthritis patients of different ages with or without carpal tunnel syndrome.

Osteoarthritis is a common degenerative disease that most frequently involves the hand. The objective was to compare clinical functional outcome measures including hand grip, pinch strength, and dexterity with various electrophysiological measures in patients of different ages with hand osteoarthritis with or without the presence of carpal tunnel syndrome (CTS). Patients with hand osteoarthritis (208 patients, 404 hands) who underwent hand-function tests and motor and sensory nerve conduction studies (NCS) between June 2015 and June 2016 were enrolled. The patients' hands were assigned to carpal tunnel syndrome (CTS) (206 hands; mean age, 56.37 ± 10.52; male:female, 46:160) or control groups (198 hands; mean age, 57.88 ± 9.68; male:female, 55:143). The strength of hand grip and lateral pinch, the time required to complete the nine-hole pegboard test (9HPT), and motor and sensory nerve conduction parameters were measured and compared across age groups and between hands with or without CTS. The CTS group showed significantly lower hand grip and lateral pinch strength, and a longer time to complete the 9HPT in comparison with the control group. Female patients showed significantly lower hand grip and lateral pinch strength than male patients. However, there was no difference in the 9HPT completion time between genders. Multivariate regression analysis identified the amplitude of the median compound muscle action potential (CMAP), age, and male gender as independent predictors of grip strength (adjusted R2 = 0.679), and amplitude of median CMAP and male gender as independent predictors of KP strength (adjusted R2 = 0.603). Velocity of median CMAP, amplitude of median sensory nerve action potential, and age were identified as independent predictors of 9HPT time (adjusted R2 = 0.329). Nerve conduction measurements were significantly related to hand-function test results, and CTS induced significant deficits in strength and performance of the affected hand.

Paretic knee extensor strength, gait velocity, and fat mass are major determinants of peak aerobic capacity in subacute stroke: observational cohort study.

The purpose of this study is to investigate major determinants of peak aerobic capacity in subacute stroke patients among body composition, balance function, walking capacity, and lower limb muscular strength. This was a retrospective observational cohort study. Eighty-three subacute stroke patients were enrolled and their medical records were retrospectively reviewed in the study (47 males; mean age: 62.95 ± 13.9 years). Gait capacity was assessed by gait velocity (10 m walk velocity:10MWV) and gait endurance (6 min walk distance:6MWD). Balance function was evaluated with Berg Balance Scale (BBS). The isometric muscular strengths of bilateral knee extensors were measured with an isokinetic dynamometer. Cardiovascular fitness was evaluated with an expired gas analyzer. In backward linear regression analyses, paretic isometric extensor strength (p < 0.001), fat mass (p = 0.005) and 10MWV (p < 0.001) are significantly correlated with peak aerobic capacity (adjusted R2 = 0.499) in all patients. Our results confirmed that paretic knee extensor strength, gait velocity, and fat mass were major determinants of peak aerobic capacity in subacute stroke. Therefore, therapeutic approaches should focus on improving gait velocity and paretic knee extensor strength in the early stages of recovery from stroke.

Feasibility of Bioimpedance Analysis to Assess the Outcome of Complex Decongestive Therapy in Cancer Treatment-Related Lymphedema.

Background: Cancer treatment-related lymphedema (CTRL) affects patients physically, psychologically and emotionally, and remains a significant quality of life issue among patients with cancer. Reliable methods to measure changes in lymphedema are required for early detection, acute intensive treatment, and long-term management. Here, we evaluated the use of bioimpedance analysis (BIA) as a tool to measure lymphedema before and after treatment. Patients and Methods: Patients with CTRL who were admitted to a secondary university hospital between October 2017 and July 2018 for complex decongestive therapy (CDT) were eligible for this prospective cohort study. Circumferential measure (CM) and BIA were used to evaluate lymphedema at admission (initial) and before discharge (follow-up, FU). Volume was calculated from the CM using the truncated cone formula. The inter-limb ratios (ILRs) of the circumference, volume, and impedance were also calculated as the unaffected limb to affected limb. Each parameter before and after treatment and correlations between parameters also were analyzed. Results: A total of 29 patients (12 upper- and 17 lower-extremity CTRL) completed were included in this analysis. Absolute value and the ILRs of circumference, volume or impedance, and extracellular water/total body water (ECW/TBW) were significantly improved at FU (p < 0.01, p < 0.05). The initial and FU absolute values, ILRs, ECW/TBW correlated significantly with each other (p < 0.01, p < 0.05). The cutoff values of ECW/TBW for moderate and severe degree of CTRL were 0.3855 and 0.3955, respectively. The changes of ILRs between initial and FU assessments were significantly different among three groups according to lymphedema severity (p < 0.01, p < 0.05). Conclusions: BIA data correlates significantly with clinical measurement, and therefore can be a practical tool in monitoring outcome measure after lymphedema treatment. In addition, BIA is more sensitive to subtle changes in lymphedema, and therefore can be useful for the long-term maintenance of lymphedema.

Assessment of Aspiration Risk Using the Mann Assessment of Swallowing Ability in Brain-Injured Patients With Cognitive Impairment.

Objectives: The purposes of this study are to determine whether there is a correlation between the Mann Assessment of Swallowing Ability (MASA) and modified MASA (mMASA) according to various cognitive status and to investigate whether the cognitive status of patients with brain damage affects the prediction of aspiration using the MASA. Methods: We retrospectively assessed 146 dysphagic patients with brain lesion due to various causes. Dysphagia was assessed using the MASA and mMASA. According to the videofluoroscopic swallowing study results, patients were divided into two groups: aspirators and non-aspirators. Patients were classified into four groups according to cognitive function according to the Korean version of Mini-mental State Examination scores: normal (>24), mild (21-24), moderate (10-20), and severe (<10) cognitive impairment. The correlation between the MASA and mMASA scores according to cognitive function were analyzed. The sensitivity, specificity, and positive and negative predictive values of the MASA scores for predicting aspiration were assessed. Results: The MASA and mMASA scores showed a significant positive correlation in all cognition groups. In patients with more severe cognitive impairment MASA scores had high sensitivity and low specificity for prediction of aspiration. On the other hand, the MASA scores had low sensitivity and high specificity for prediction of aspiration in the normal and mild cognitive impairment groups. Conclusions: The MASA and mMASA scores correlated with each other in patients with various levels of cognitive function. Interestingly, this study results demonstrated that patients with good cognitive function may have false negative results of MASA screening due to low sensitivity. Thus, when interpreting the MASA results, the impact of cognitive status should be taken into consideration.

Improvement in Pulmonary Function with Short-term Rehabilitation Treatment in Spinal Cord Injury Patients.

Cervical and upper thoracic spinal cord injury causes impairments in respiratory muscle performance, leading to variable degrees of pulmonary dysfunction and rendering deep breathing difficult for affected individuals. In this retrospective study, we investigated the effects of self-directed respiratory muscle training in this context by assessing pulmonary function relative to spinal cord injury characteristics. A total of 104 spinal cord injury patients (tetraplegia/paraplegia; 65/39, acute/subacute/chronic; 14/42/48) were admitted for short-term (4-8 weeks) in-patient clinical rehabilitation. Initial evaluation revealed a compromised pulmonary function with a percentage of predicted value of 62.0 and 57.5 in forced vital capacity in supine and forced vital capacity in sitting positions, respectively. Tetraplegic patients had more compromised pulmonary function compared with paraplegic patients. At follow-up evaluation, the percentage of predicted value of forced vital capacity in supine and sitting position improved overall on average by 11.7% and 12.7%, respectively. The peak cough flow improved by 22.7%. All assessed pulmonary function parameters improved significantly in all subgroups, with the greatest improvements found in patients with tetraplegia and subacute spinal cord injury. Therefore, short-term self-directed respiratory muscle training should be incorporated into all spinal cord injury rehabilitation regimens, especially for patients with tetraplegia and subacute spinal cord injury, as well as those with chronic spinal cord injury.

The Effects of a Motorized Aquatic Treadmill Exercise Program on Muscle Strength, Cardiorespiratory Fitness, and Clinical Function in Subacute Stroke Patients: A Randomized Controlled Pilot Trial.

OBJECTIVE: The aim of this study was to assess whether the effects of a motorized aquatic treadmill exercise program improve the isometric strength of the knee muscles, cardiorespiratory fitness, arterial stiffness, motor function, balance, functional outcomes, and quality of life in subacute stroke patients. DESIGN: Thirty-two patients were randomly assigned to 4-wk training sessions of either aquatic therapy (n = 19) or land-based aerobic exercise (n = 18). Isometric strength was measured using an isokinetic dynamometer. Cardiopulmonary fitness was evaluated using a symptom-limited exercise tolerance test and by measuring brachial ankle pulse wave velocity. Moreover, motor function (Fugl-Meyer Assessment [FMA] and FMA-lower limb [FMA-LL]), balance (Berg Balance Scale [BBS]), Activities of daily living (Korean version of the Modified Barthel Index [K-MBI]), and quality of life (EQ-5D index) were examined. RESULTS: There were no intergroup differences between demographic and clinical characteristics at baseline (P > 0.05). The results shows significant improvements in peak oxygen consumption (P = 0.02), maximal isometric strength of the bilateral knee extensors (P < 0.01) and paretic knee flexors (P = 0.01), FMA (P = 0.03), FMA-LL (P = 0.01), BBS (P = 0.01), K-MBI (P < 0.01), and EQ-5D index (P = 0.04) after treatment in the aquatic therapy group. However, only significant improvements in maximal isometric strength in the knee extensors (P = 0.03) and flexors (P = 0.04) were found within the aquatic therapy group and control group. CONCLUSIONS: Water-based aerobic exercise performed on a motorized aquatic treadmill had beneficial effect on isometric muscle strength in the lower limb. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Articulate the rationale for including walking on an aquatic treadmill in the rehabilitation of subacute stroke patients; (2) Describe the beneficial effects of a motorized aquatic treadmill exercise program in the rehabilitation of subacute stroke patients; and (3) Determine the appropriate indications for incorporating a motorized aquatic treadmill exercise program in the rehabilitation of subacute stroke patients.Level: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Effects of a 6-Week Aquatic Treadmill Exercise Program on Cardiorespiratory Fitness and Walking Endurance in Subacute Stroke Patients: A PILOT TRIAL.

OBJECTIVE: To assess the feasibility and safety of a 6-week course of water walking performed using a motorized aquatic treadmill in individuals with subacute stroke for cardiorespiratory fitness, walking endurance, and activities of daily living. METHODS: Twenty subacute stroke patents were randomly assigned to aquatic treadmill exercise (ATE) or land-based exercise (LBE). The ATE group (n = 10) performed water-based aerobic exercise on a motorized aquatic treadmill, and the LBE group (n = 10) performed land-based aerobic exercise on a cycle ergometer. Both groups performed aerobic exercise for 30 minutes, 5 times per week for 6 weeks. Primary outcome measures were 6-minute walk test for walking endurance and cardiopulmonary fitness parameters of a symptom-limited exercise tolerance test, and secondary measures were Korean version of the Modified Barthel Index (K-MBI) for activities of daily living. All variables were assessed at baseline and at the end of the intervention. RESULTS: The ATE group showed significant improvements in 6-minute walk test (P = .005), peak oxygen uptake ((Equation is included in full-text article.)O2peak; P = .005), peak heart rate (P = .007), exercise tolerance test duration (P = .005), and K-MBI (P = .008). The LBE group showed a significant improvement only in K-MBI (P = .012). In addition, improvement in (Equation is included in full-text article.)O2peak was greater in the ATE than in the LBE group. CONCLUSION: This preliminary study showed that a 6-week ATE program improved peak aerobic capacity and walking endurance in patients with subacute stroke. The improvement in (Equation is included in full-text article.)O2peak after an ATE exercise program was greater than that observed after an LBE program. Therefore, ATE effectively improves cardiopulmonary fitness in patients with subacute stroke.