Understanding Antithrombotic Agents for Rehabilitation Therapy: A Comprehensive Narrative Review.

In rehabilitation medicine, attention must be paid to the medication. Among them, antithrombotic drugs are used for the initial treatment and secondary prevention of stroke, so as a basic knowledge, the pharmacological actions, characteristics, indications, and precautions for the use of antithrombotic drugs should be known. Antithrombotic agents are divided into antiplatelet agents and anticoagulants, and the appropriate antithrombotic agent is selected according to the main disease or condition. Antiplatelet agents include aspirin, clopidogrel, ticlopidine, prasugrel, ticagrelor, and cilostazol. Each antiplatelet agent has a different mechanism of action, characteristics, and indications, and should be prescribed with due consideration. Anticoagulants include heparin, synthetic Xa inhibitors, direct oral anticoagulants (DOACs), synthetic antithrombin agents, and warfarin. Knowledge of the mechanism of action, characteristics, and indications of each anticoagulant is necessary, as well as monitoring and dose adjustment. With regard to ischemic cerebrovascular disease (ICD) and antithrombotic agents, the first step is to classify cerebral infarction and to determine whether antiplatelet agents or anticoagulants should be used. Bleeding and recurrence prevention are important considerations in the selection of appropriate antithrombotic agents for the pathophysiology of ICD.

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

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

Two Cases Showing That Cilostazol Administration Leads to an Increase in Cerebral Blood Flow and Has a Positive Effect on Rehabilitation.

Cilostazol is a drug that has both antiplatelet and vasodilatory effects. To examine the effects of cilostazol on cerebral blood flow and rehabilitation following stroke, cilostazol was administered to two patients with chronic atherothrombotic cerebral infarction. In both patients, cilostazol administration effectively increased cerebral blood flow and promoted rehabilitation. Therefore, cilostazol was considered to be a useful agent for improving the clinical condition of patients suffering from chronic cerebral infarction. Further clinical studies on the effective use of cilostazol for rehabilitation in stroke patients are needed.

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

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

Immediate Effects of Electrical Stimulation on Oropharyngeal Structure and Laryngeal Vestibular Closure: A Pilot Study in Healthy Subjects.

Objectives: This study examined the immediate effects of neuromuscular electrical stimulation (NMES) on the dynamics of oropharyngeal structure and laryngeal vestibular closure (LVC) in healthy subjects. Methods: Ten healthy male volunteers participated in this controlled, before-and-after, videofluoroscopic swallowing pilot study. The study was conducted in four phases (each performed twice): (1) saliva swallow (SS) before evaluation (BEFORE), (2) NMES while at rest with no SS (NMES AT REST), (3) SS during NMES (DURING NMES), and (4) SS to examine the aftereffects of NMES (AFTER). We measured distances that oropharyngeal structures moved in the NMES AT REST phase, and we analyzed the kinematics of saliva swallowing primarily in the BEFORE and AFTER phases. Results: Four changes in the morphology of the oropharyngeal structure caused by NMES AT REST were statistically significant: anterior-upward displacement of the hyoid bone and larynx, stretch of the laryngeal vestibule, and posterior ridge of the tongue root. Regarding the kinematics measured during SS, although there was no significant change in LVC reaction times, LVC duration in the AFTER phase was significantly longer than BEFORE. Regarding maximal displacement of the hyoid bone, there was significantly greater movement AFTER than BEFORE. As additional exploratory outcomes, the velocity of hyoid bone movement was significantly slower, and the hyoid-to-larynx approximation was significantly smaller, DURING NMES than AFTER. Conclusions: Longer duration of LVC might be caused by adaptive learning with NMES-induced structural changes in the oropharynx. Further clinical studies are warranted to determine whether this approach improves dysphagia, which impairs LVC.

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

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